Columbia  ^nitJer^itp 

CoUege  of  ^f)^&imn&  anb  burgeons! 
Hibrarp 


FISTULA,  HAEMORRHOIDS,  PAINFUL  ULCER, 
STRICTURE,  PROLAPSUS, 


AND   OTHER 


Diseases  of  the  Rectum: 


THEIR 


DIAGNOSIS  AND  TREATMENT. 


BY 


WILLIAM  ALLINGHAM,  M.D., 

Fellow  of  the  Royal  College   of  Surgeons  of  England ;   Surgeon   to  St.  Mark's 
Hospital  for  Fistula  and  other  Diseases  of  the  Rectum,  etc. 


FOURTH  REVISED  AND  ENLARGED  EDITION. 
WITH    ILLUSTRATIONS 


NEW  YORK : 
BERMINGHAM  &  CO.,  UNION  SQUARE. 

i882c 


W.  L.  Mershon  &  Co., 

Printers^  Electrotypers  and  Binders^ 
Rahway,  N.  J. 


o 


oo 


C3 

2s: 


PREFACE  TO  THE  FOURTH  EDITION. 


That  this  book  has  not  been  written  in  vain,  appears  to  be 
evidenced  by  the  facts,  that  three  large  editions  have  been 
sold  in  this  country  and  in  England,  that  it  has  been  trans- 
lated into  the  French,  Italian,  Spanish  and  Russian  languages, 
and  that  a  fourth  edition  is  now  demanded,  the  third  having 
long  been  exhausted.  An  endeavor  has  been  made  to  remove 
obscurities,  correct  errors,  and  revise  generally,  without 
much  enlarging  the  work.  An  Index  is  added,  which  it  is 
hoped  will  facilitate  reference. 


CONTENTS. 


PACE 

Chapter  I. — Introductory. — Statistics 9 

Chapter  II. — Examination  of  the  Patient — Exploration  of  the 
Rectum  ;  Use  of  the  Speculum ;  Introduction  of  the  Hand ; 
Dilatation  of  the  Sphincters ii 

Chapter  III. — Fistula  in  Ano — Causes;  Abscesses  and  Treat- 
ment ;  Use  of  Drainage  Tubes  ;  Various  Forms  of  Fistula ; 
Examination  of  a  Patient  with  Fistula  or  Sinus ;  Dangerous 
kinds  of  Fistulse  ;  Treatment  of  Blind  External  Fistula  ;  Spon- 
taneous cure  of  Fistula ;  Cases ;  Cure  by  Treatment  without 
Cutting l6 

Chapter  IV. — Fistula  and  its  Treatment  by  Elastic  Liga- 
ture       28 

Chapter  V. — Operations  on  Fistula  in  Ano — Directions  for  the 
Operation  ;  Internal  Fistula  ;  Causes  of  Incontinence  of  Faeces, 
how  to  avoid  ;  Dressing  and  Healing  Wounds  after  Operating  ; 
Treatment  of  difficult  Cases 34 

Chapter  VI. — Fistula  in  Conjunction  with  Phthisis — Opin- 
ions of  Authors  ;  Discussion  of  this  Subject  ;  Cases  ;  Question 
of  Cough ;  Treatment  of  Fistulous  Sinuses  in  Consumptive 
Patients 47 

Chapter  VII. — Hemorrhoids — Classification — External  Piles, 

Diagnosis,  Varieties  and  Treatment 60 

Chapter  VIII. — Internal  Hemorrhoids — Causes,  and  Opinions 
of  French  Authors  ;  Verneuil's  Theory  of  Predisposing  Causes  ; 
Discussion  ;  Varieties  of  Internal  Piles  ;  Structure,  etc.  ;  Ques- 
tion of  Operating ;  Cases ;  Dangers  resulting  from  Losses  of 
Blood  ;  Protrusion  of  Haemorrhoids  ;  Cases  best  suited  to  Con- 
stitutional Treatment ;  Connection  of  Diseases  of  the  Uterus  • 
and  Haemorrhoids,  with  cases 66 


VI  CONTENTS. 

PAGR 

Chapter  IX. — Operations  on  Internal  Haemorrhoids — Eleven 
Methods  Described — Excision  of  Hsemorrhoids  ;  Treatment 
by  the  Ecraseur  ;  Application  of  Caustics  ;  Injection  of  Carbolic 
Acid,  etc.  ;  Cauterization  "  ponctuee  ;"  Cauterization  "  linear ;  " 
Operations  by  Galvanic  Cautery  ;  Removal  of  Hsemorrhoids  by 
Clamp,  Scissors,  and  Heated  Iron  ;  Dilatation  of  Sphincter 
Muscles  ;  Treatment  of  Internal  Hsemorrhoids  by  Crushing ; 
Treatment  of  Internal  Piles  by  Ligature  ;  Author's  Mode  of 
Operating  ;  After  Treat  ment ;  Question  of  Pain  ;  Retention 
of  Urine  ;  Success  and  Statistics  of  the  Operation  ;  Exceedingly 
small  Mortality 85 

Chapter   X. — Complications  of  H/emorrhoids — Impaction  of 

Faeces iio 

Chapter    XI. — HyEMORRHAGES   after    Operations— Varieties ; 

Treatment  and  Cases 1 14 

Chapter  XII, — Procidentia  Recti — Definition,  Diagnosis,  etc.  ; 

in  Children  ;  in  Adults  ;  Permanent  Cure  ;  Cases 122 

Chapter  XIII. — Polypus    Recti — ^Varieties  ;  Diagnosis  ;  Cases ; 

Treatment „ 130 

Chapter  XIV. — Pruritus Ani — Causes;  Varieties;  Treatment..  136 

Chapter  XV. — Fissure  and  Painful  Irritable  Ulcer  of  the 
Rectum — Diagnosis  ;  Connection  with  Uterine  Disease  ;  Com- 
bined with  Polypus ;  Cure  by  Simple  Treatment ;  With  Cases  ; 
Treatment  by  Division  of  Sphincter  Muscles  ;  Method  of  Operat- 
ing ;  Nervous  Symptoms  associated  with  Fissure  ;  Why  are  these 
Ulcers  so  Painful  ?  Treatment  by  complete  Dilatation  of  the 
Anus  ;  Results 143 

Chapter  XVI. — Impaction   of  Faeces — Diagnosis,  Causes,  and 

Cases  ;  Treatment ;  Concretions  in  the  Rectum 159 

Chapter  XVII. — Ulceration  and  Stricture  of  the  Rectum — 
Symptoms,  Diagnosis  ;  Statistics  of  Seventy  Cases  in  Hospital ; 
Observations  ;  Linear  Rectotomy  ;  Twenty-nine  Cases  in  Private 
Practice,  with  Observation  ;  Causes  of  Ulceration  and  Stricture 
with  reference  to  Syphilis  and  Venereal  Sores  ;  Opinions  of 
French,  American,  and  English  Authorities  ;  Treatment ; 
Stricture  of  the  Rectum  without  Ulceration  ;  Treatment,  etc. . .   166 


CONTENTS.  Vli 

PAGE 

Chapter  XVIII. — Cancer  of  the  Rectum — Observations  and 
Varieties  ;  Treatment ;  Chian  Turpentine  ;  Operations  for  Relief 
or  Possible  Cure  ;  Extirpation  ;  Cases — Thirteen  Partial  Exci- 
sions, Sixteen  Complete,  by  the  Author ;  Criticism  on  the 
Operation  ;  Colotomy  in  Cancer  ;  Thirty-nine  Cases  by  the 
Author  ;  Mode  of  Performing  Colotomy 202 

Chapter  XIX. — Rodent  or  Lupoid  Ulcer — Diagnosis;  Treat 

ment  ;  Cases 232 

Chapteb  XX. — Villous  Tumor  of  the  Rectum. — Descriptions  ; 

Cases , ....   239 

Chapter    XXL — Miscellaneous — Neuralgia    of    the     Rectum  ; 

Removal  of  Coccyx  ;  Inflammation  of  the  Rectum 245 


DISEASES  OF  THE  RECTUM. 


CHAPTER  I. 

INTRODUCTORY. 

Rectal  diseases  are  among  the  most  common  that  affect 
civilized  humanity.  They  are  of  rare  occurrence  in  barbar- 
ous countries.  From  information  obtained  when  traveling  in 
South  Africa,  I  have  reason  to  believe  that  the  natives  of 
that  part  of  the  world  very  seldom  suffer  from  these  affec- 
tions, but  some  of  my  medical  friends  practicing  in  India, 
and  also  in  China,  have  informed  me  that  the  natives  of 
those  countries  are  not  exempt,  and  that  severe  cases  of 
various  kinds  of  rectal  disease  are  not  uncommon.  The 
native  doctors,  treat  bleeding  piles  by  thrusting  red-hot  skew- 
ers into  the  centpe  of  each  tumor.  It  is  curious  that  a  some- 
what similar  plan  has  been  recently  advocated  by  a  London 
surgeon.  Food  and  alcohol,  sedentary  indoor  occupations, 
and  defects  in  clothing,  have  much  influence  in  the  causa- 
tion of  these  maladies,  which  though  not  actually  dangerous 
to  life,  certainly  give  rise  to  a  vast  amount  of  suffering,  by 
which  I  mean  not  only  pain,  but  also  the  distress  arising 
from  inability  to  work  for  daily  bread.  Both  laborious  and 
and  sedentary  occupations  are  often  rendered  almost 
unendurable. 

It  is  true  that  the  majority  ot  these  affections  are  very 
amenable  to  proper  treatment ;  the  amount  of  benefit  that  can 
be  conferred  by  a  well  skilled  surgeon  is  really  remarkable  ; 
but  there  is  the  opposite  proposition  to  be  considered.  When 
diseases  of  the  rectum  are  neglected,  or  when  the  surgeon 
prescribes  confection  of  senna  and  gall-ointment  in  every  case 
cures  do  not  frequently  result. 

An  accurate  diagnosis  in  rectal  diseases  is  all  important, 
and  to  prescribe  for  patients  suffering  from  these  maladies 
without  examining  them,  both  ocularly  and   digitally,  is  not 

D 


lO  INTRODUCTORY. 

only  false  delicacy,  but  radically  wrong,  and  likely  to  bring 
the  treatment  of  these  diseases  into  contempt. 

It  still  constantly  occurs  to  me  to  see  patients  who  have 
been  for  a  long  time  under  treatment  by  qualified  practition- 
ers, and  to  whom  medicine  and  ointment  have  been  plenti- 
fully prescribed,  yet  no  digital  examination  has  been  made; 
perhaps,  only  a  look  has  been  vouchsafed,  and  the  disease 
diagnosed  and  treated  as  piles,  whereas  fistula,  or  ulceration 
or  even  malignant  disease  has  been  present. 

Some  forms  of  rectal  disease  are  much  more  common 
than  others,  notably  fistula  and  piles.  The  popular  mind 
seems,  indeed,  to  recognize  the  existence  of  only  these  two 
diseases  of  the  rectum,  for  all  affections  of  this  part  are  gen- 
erally classed  by  the  public  under  one  or  other  of  these 
heads.  The  following  is  a  table  showing  the  relative  oropor- 
tions  found  in  4000  cases  taken  from  my  own  practice  at  St. 
Mark's  Hospital: — 

Analysis  of  4000  consecutive  cases  observed  by  Mr.  Allingham 
in  the  Out-patie?its'  Departinent  of  St.  Mark's  Hospital. 

Fistula* , 1208 

Abscess,   196  (of  these  151  became  fistulse,  the  rest  prob- 
ably were  cured) 45 

Haemorrhoids,  internal 863 

Haemorrhoids  external 102 

Fissure  or  painful  ulcer 446 

Syphilitic  diseases  of  the  anus  and  rectum 348 

Ulceration  (neither  malignant  nor  syphilitic) 190 

Constipation 185 

Pruritus  ani 180 

Stricture  of  the  rectum  (with  or  without  ulceration) 178 

Cancer  of  the  rectum 105 

Procidentia 53 

Polypus  without  fissure 16 

Hsemorrhage  (cause  not  ascertained) 15 

Impaction  of  fasces 14 

Neuralgia '. 12 

Dysentery 12 

Spasmodic  contraction  of  the  sphincter  (no  fissure) 8 

Proctitis 7 

Foreign  bodies  in  the  rectum -  5 

I^ecrosis  of  bone  (sacrum  and  tuberosity  of  the  ischium). .  4 

Rodent  ulcer 2 

Vicarious  menstruation  from  the  rectum 2 

4000 

*0f  these  cases  of  fistula  there  were  172  that  presented  more  or  less 
marked  symptoms  of  affection  of  the  lungs,  viz:  haemoptysis,  frequent 
cough,  or  want  of  reasonance  in  some  part  of  the  chest. 


EXAMINATION    OF    PATIENTS.  II 

Some  of  my  critics  have  thought  the  above  table  mislead- 
ing, and  that  haemorrhoids  are  more  common  than  fistulse.  I 
do  not  say  that  this  may  not  be  the  case,  if  we  take  into  con- 
sideration the  middle  and  upper  classes  as  well  as  the  labor- 
ing population,  whose  cases  alone  are  included  in  my  table. 
Slight  cases  of  piles  did  not  often  present  themselves  at  the 
hospital,  for  the  laboring  man  or  woman  struggles  on  under 
an  attack  which  would  certainly  bring  the  well-to-do  to  the 
surgeon.  In  my  private  practice  I  find  during  the  last 
seven  years  I  have  treated  a  few  more  cases  of  haemorrhoids 
than  of  fistula,  but  it  must  be  observed  that  a  large  number 
of  the  former  were  of  a  very  slight  nature,  or  suffering  only 
from  external  piles,  and  not  requiring  any,  or  more  than  triv- 
ial, operative  interference  for  their  cure. 


CHAPTER  II. 

EXAMINATION    OF    PATIENTS. 

There  are  certain  questions  which  it  is  desirable  to  ask 
the  patient  when  inves1,igating  a  case  of  rectal  disease,  in 
order  that  nothing  may  be  forgotten  or  overlooked. 

It  should  be  remembered  that  we  have  not  done  enough 
when  we  have  discovered  that  a  patient  has  a  certain  mal- 
ady; it  is  our  duty  then  to  find  out  if  any  other  disease 
coexists.  Thus,  I  often  see  a  correct  diagnosis  made,  as  far 
as  regards  piles,  but  at  the  same  time,  a  fissure,  or  fistula,  or 
ulceration,  or  even  malignant  disease  of  the  bowel,  has 
escaped  observation. 

The  following  are  the  principal  queries  I  generally  put : 
Is  there  any  pain  ?  If  so,  of  what  character  ?  Let  the 
patient  describe  it — leading  questions  should  be  avoided. 
Does  the  pain  exist  always,  or  is  it  intermittent  or  par- 
oxysm.al  ?  Is  the  pain  set  up  or  increased  by  defecation  ? 
Does  it  come  on  as  the  bowels  are  acting,  or  does  it  follow 
immediately,  or  some  time  after  the  action  ?  How  long 
does  the  pain  last  ?  Does  it  pass  away  entirely,  only  to 
recur  again  on  going  to  stool  ?  Does  anything  protrude  on  the 
bowels  acting,  or  on  making  exertion  ?  If  so,  does  it  bleed  ? 
Does  it  go  back  spontaneously,  or  has  the  patient  to  return  it.^ 


12  EXAMINATION    OF    PATIENTS. 

Is  there  any  discharge  ?  if  so,  what  is  its  nature  ?  is  it  of 
offensive  odor  ?  Is  the  patient  constipated,  or  does  he  suffer 
from  diarrhoea  ?  What  is  the  character  of  the  fecal  evacu- 
ation, as  to  size,  form,  etc.  ? 

Has  the  patient  incontinence  of  wind  or  faeces  ?  Is  there 
any  hereditary  tendency  to  rectal  disease  ?  Does  the  patient 
cough,  or  is  there  any  proclivity  to  chest  affections  ?  Ascer- 
tain the  state  of  the  liver;  and  should  an  operation  be  in 
view,  never  fail  to  examine  the  urine;  any  advanced  dis- 
ease of  the  kidneys  will,  in  all  probability,  render  an  opera- 
tion inadmissible.  In  the  present  day  much  is  ascribed  to 
gout,  and  it  is  well  to  bear  in  mind  that  a  gouty  person  sud- 
denly confined  to  bed  is  liable  to  get  an  attack  which  may, 
at  all  events,  unpleasantly  complicate  the  case;  lastly, 
inquire  into  habits,  especially  with  reference.to  the  consump- 
tion of  alcoholic  drinks.  I  am  by  no  means  one  of  those 
who  think  that  a  moderate  indulgence  in  beer  or  light  wine 
damaging  to  the  hard-worked  man,  but  a  patient  saturated 
with  alcohol  is  the  worst  subject  a  surgeon  can  have  to  deal 
with.  In  such  a  case  I  always  insist  on  four  weeks  total 
abstinence,  and  at  the  same  time  that  the  patient  should  be 
subjected  to  preparatory  treatment  before  anything  in  the 
way  of  operation  is  attempted. 

In  women,  inquire  into  the  condition  of  the  uterus,  and  if 
any  suspicion  is  aroused,  make  such  investigation  as  will 
satisfy  yourself  as  to  its  state. 

When  your  verbal  interrogations  are  concluded,  make 
your  examination.  There  are  various  postures  and  methods 
in  which  this  examination  can  be  conducted.  Some  sur- 
geons prefer  the  patient  to  kneel  on  a  chair  and  lean  over 
the  back;  others  to  kneel  on  a  sofa,  the  head  being  lower 
than  the  buttocks;  others  the  lithotomy  position;  but  on  the 
whole,  I  think  the  most  comfortable  and  delicate  position 
for  the  patient,  and  that  most  generally  convenient  for  the 
surgeon,  is  to  lie  on  the  right  side,  on  a  couch,  with  the 
knees  drawn  up  to  the  abdomen.  In  special  examinations 
to  discover  growths  and  strictures,  I  often  direct  the  patient 
to  stand  up  and  bear  down;  in  this  manner  the  diseased 
parts  will  be  brought  nearer  to  the  anus,  and  so  enable  you 
to  reach  nearly  a  couple  of  inches  higher  than  you  can  when 
the  patient  is  lying  down  in  the  usual  position,  even  if  he 
strain  down. 

To  commence.  Externally,  what  is  to  be  seen  ?  Note 
any  discoloration,  the  condition  of  the  anus,  patulous,  con- 


EXAMINATION    OF   PATIENTS. 


13 


tracted  or  nipple-shaped.  Look  for  tumors,  ulceration,  or 
fistulous  orifices;  feel  around  outside  the  anus  with  the  fore- 
finger, for  induration  in  any  part;  by  this  means  the  situa- 
tion of  an  abscess  or  sinus  may  be  discovered,  and  the  con- 
dition of  the  sphincter  as  to  spasm  observed.  Then,  if  pos- 
sible, administer  an  injection  of  warm  water.  I  hold  that 
no  examination  of  the  bowel  can  be  considered  complete  if 
this  be  dispensed  with.  After  the  contents  of  the  bowel  are 
voided,  you  see  what  protrusion  has  taken  place,  if  any; 
remark  its  character  in  every  way,  particularly  as  to  struc- 
ture, vascularity,  mode  of  origin  from  the  bowel,  by  pedun- 
cle or  otherwise;  finally,  examine  the  interior  of  the  bowel 
with  the  finger.  Never  neglect  this.  Much  information — 
to  the  initiated  all  that  is  needed — is  to  be  obtained  by  pass- 


FlG.  X. 


Fig.  a. 


Mr.  AUingham's  Four-bladed  Speculum. 


Speculum  Anl« 


ing  the  instructed  and  practiced  finger  into  the  rectum; 
internal  fistulous  orifices,  polypi,  minute  ulcerations,  fissures, 
etc.,  can  all  be  easily  detected.  Although  personally  I  do 
not  use  a  speculum  very  frequently,  in  some  cases  it  is  a 
valuable  aid  to  diagnosis.  I  have  had  many  varieties  of 
that  instrument  constructed,  to  be  used  with  or  without 
artificial  light;  but  for  ordinary  use  the  plated  metal  specu- 
lum employed  at  St.  Mark's  Hospital  is,  in  my  opinion,  the 
best.  It  is  open  up  one  side  and  at  both  ends,  and  has  a 
well-fitting  plug;  the  whole  is  so  shaped  as  to  resemble  as 
much  as  possible  a  forefinger.  It  is  made  by  most  instru- 
ment makers — Ferguson,  Weiss,  Krohne,  and  others.  Some 
surgeons  prefer  the  bi-valve  speculum,  and  I  like  it  also;  its 


14  EXAMINATION    OF    PATIENTS. 

only  drawbacks  are  some  difficulty  of  introduction,  and  the 
risk  of  injuring  the  mucous  membrane  during  withdrawal. 

When  you  desire  to  explore  the  rectum  high  up,  you  may, 
with  advantage,  use  a  long  metal  tube  with  the  interior 
"  nickeled,"  one  end  being  trumpet-shaped  and  large.  The 
smaller  end  may  be  about  three-quarters  of  an  inch  in 
diameter,  and  it  is  very  easily  introduced  into  the  bowel,  by 
using  as  the  plug  a  small  india-rubber  bag,  which  you  can 
inflate  with  air  by  means  of  a  syringe.  Useful  as  the  above 
is,  to  make  thorough  examination  of  the  rectum  for  the  pur- 
pose of  diagnosing  the  existence  of  ulcerations,  malignant 
or  other  growths,  too  high  up  the  bowel  to  reach  with  the 
finger,  it  is  best  to  place  the  patient  under  the  influence  of 
an  anaesthetic,  and  in  the  prone  position,  with  the  hips  well 
elevated  upon  hard  pillows,  so  that  the  intestines  will  gravi- 
tate toward  the  diaphragm,  and  then  gradually  and  gently, 
by  palpation,  to  dilate  the  sphincters,  taking  four  or  five 
minutes  in  accomplishing  this  operation.  When  thoroughly 
done  the  whole  rectum  is  opened  to  view,  and  if  one  or  two 
retractors  are  also  used,  nothing  can  escape  careful  obser- 
vation. I  need  scarcely  say  before  any  thorough  examina- 
tion is  made  the  bowel  must  be  well  cleared  out  by  aperients 
and  injections,  and  also  you  must- be  provided  with  sponges 
mounted  on  holders,  to  wipe  away  all  discharge  that  would 
impede  your  view. 

Even  when  this  has  been  done  something  more  may  be 
desirable,  and  that  is  the  introduction  of  the  hand  and  arm 
into  the  intestine.  In  the  year  1867  I  first  introduced  my 
hand  and  arm  into  the  bowels  of  a  woman  at  St.  Mark's 
Hospital,  and  found  a  malignant  stricture  in  the  sigmoid 
flexure.  From  that  time  I  have  on  many  occasions  repeated 
this  manoeuvre,  and  have  saved  several  lives.  In  one  case, 
which  I  saw  with  Dr.  Wilson  Fox  and  Mr.  Towne,  of  Kings- 
land,  I  found  and  completely  stretched  a  band  of  false  mem- 
brane or  peritoneum,  which  was  binding  down  the  bowel  as 
it  crossed  the  brim  of  the  pelvis;  the  obstruction  was  relieved 
and  the  patient  recovered. 

Up  to  the  year  1873,  I  had  never  introduced  my  hand  into 
the  male  rectum,  believing  that  it  was  impossible  that  a  man's 
hand  could  be  passed  through  the  comparatively  unyielding, 
narrow  inlet  to  the  male  pelvis;  but.  learning  that  the  late 
Professor  Simon,  of  Heidelberg,  had  accomplished  this  I 
have  on  many  occasions  (my  hand  being  small)  followed  his 
example,  without  inflicting  any  injury.     I  do  not,  however. 


EXAMINATION    OF    PATIENTS.  I5 

think  that,  at  all  events  in  a  man,  much  aid  to  diagnosis  is 
gained,  the  hand  being  so  firmly  compressed  in  the  sigmoid 
flexure  as  to  prevent  extensive  manipulation. 

I  need  scarcely  say  in  this  proceeding  the  utmost  gentle- 
ness should  be  used,  and  that  a  small  hand  is  absolutely 
necessary.  Dr.  Heslop,  of  Birmingham,  relates  in  the  Lancet, 
May  nth,  1872,  two  cases  of  death  in  women  after  passing 
the  hand  into  the  rectum,  and  I  think,  justly  infers  that  the 
operation  was  the  cause  of  rupture  of  the  bowels  close  to  or 
above  the  stricture.  I  have  myself  seen  death  result  from 
this  procedure  in  a  case  "where  I  believe  no  undue  violence 
was  employed.  My  opinion  is  that  in  this  operation,  where 
a  stricture  exists,  it  should  not  be  forcibly  or  widely  dilated, 
and  that  the  dilatation  should  not  befollowed  by  copious 
enemata,  which  will  unduly  distend  the  weak  part  of  the 
intestine,  and  cause  much  straining;  it  is  better  not  even  to 
give  any  purgative  for  at  least  forty- eight  hours,  and  I  think 
it  wise  to  administer  repeatedly  small  doses  of  opium. 

Referring  again  to  the  condition  of  the  rectum  after  well 
dilating  the  sphincters,  I  wish  to  point  out  how  easily  opera- 
tions may  be  performed — a  large  bi-valve  vaginal  speculum 
may  be  introduced,  or  Bozeman's  duck-bill,  and  recto-vesical 
openings  may  be  readily  closed.  I  have  now  on  three 
occasions  successfully  sewed  up  large  vesico-rectal  fistulae 
made  by  experienced  surgeons  in  performing  lithotomy.  I 
have  removed  a  piece  of  stick  three  and  and  a  half  inches  in 
length,  which  a  man  had  introduced  into  his  rectum,  and 
allowed  to  escape  into  the  bowel,  where  it  got  fixed  cross- 
wise in  the  rectum,  so  high  up  as  not  to  be  felt  by  the  finger, 
and  also  an  impaction  of  faeces  measuring  three  inches  in 
diameter,  the  nucleus  of  which  was  a  large  biliary  calculus. 
As  regards  impactions  generally^  after  dilatation  of  the 
sphincters,  the  whole  mass  can  be  removed  at  one  sitting, 
and  this  is  a  great  adventage.  I  shall  have  occasion,  further 
on,  to  again  consider  this  question  of  so-called  "  forcible 
dilatation."  In  examining  the  rectum  in  women.  Dr. 
Horatio  Storer,  of  Boston,  U.  S.,  has  recommended  eversion 
by  the  fingers  passed  into  the  vagina.  This  method  is  use- 
ful in  women  who  have  borne  children,  but  not  in  the  young 
and  unmarried.  Moreover,  it  is  only  the  anterior  wall  of  the 
rectum,  and  that  not  high  up,  that  this  method  enables  you 
to  examine;  by  putting  your  fingers  into  the  vagina  you  can- 
not bring  down  the  posterior  wall  of  the  rectum,  as  I  have 
assured  myself  on  many  occasions. 


1 6  FISTULA    IN    ANO. 

CHAPTER  III. 

FISTULA    IN    ANO. 

Fistula  is,  at  all  events  in  hospital  practice,  the  most  com- 
mon rectal  disease  affecting  the  adult.  Out  of  4000  cases, 
taken  consecutively  and  without  selection,  at  St.  Mark's 
Hospital,  from  the  out-patient  department,  there  were  1075 
persons  suffering  from  fistula,  and  196  from  abscess,  of  which 
151  subsequently  became  fistulae,  so  that  more  than  one- 
fourth  of  the  whole  cases  treated  were  fistula.  I  have 
recently  examined  the  records  of  the  in-patients  at  St.  Mark's 
Hospital  during  several  years,  and  these  show  that  two-thirds 
of  those  operated  upon  were  cases  of  fistula.  There  is  one 
great  difficulty  in  making  deductions  from  statistics,  which 
deserves  mention;  it  is  due  to  the  fact  that  many  patients 
suffer  from  more  than  one  malady.  It  constantly  happens 
that  a  fistula  is  found  in  connection  with  haemorrhoids,  either 
as  the  substantive  disease,  or  as  a  complication.  Again,  a 
fissure  or  circular  ulcer  often  has  a  sinus  running  from  it,  so 
that  it  may  fairly  be  considered  as  the  opening  of  an  internal 
fistula,  and  the  case  called  a  fistula,  or  the  sinus  is  not 
detected,  and  the  case  is  called  ulcer  or  fissure,  and  so  error 
creeps  in. 

Men  are  more  subject  to  fistula  than  women. 

This  disease  is  most  frequently  met  with  during  middle 
age,  but  it  is  by  no  means  restricted  to  that  period  of  life.  I 
have  operated  upon  an  infant  in  arms,  and  upon  a  man 
seventy-eight  years  of  age.  * 

The  causes  of  fistula,  or  abscess  ending  in  fistula,  are  many 
and  various,  and  several  causes  may  combine  to  produce  the 
result. 

These  may  be  generally  specified :  Injury  to  the  anus, 
injury  to  the  mucous  membrane  of  the  bowel  by  very  costive 
motions,  by  straining  at  stool,  by  foreign  bodies  swallowed 
(fish  bones,  and  the  bones  of  rabbits  are  occ'asionally  found 
in  rectal  abscesses),  exposure  to  wet  and  cold,  and  particu- 
larly sitting  upon  damp  seats  after  exercise,  when  the  parts 
are  hot  and  perspiring — I  have  traced  many  cases  of  rectal 
abscess  to  sitting  on  the  outside  of  an  omnibus  shortly  after 
active  exertion;  the  scrofulous  diathesis;  and  certain  depraved 
conditions  of  the  blood,  such  as  frequently  give  rise  to  boils 
or  carbuncles.     Here  I  would  observe  that  sudden  and  deep- 


FISTULA    IN    ANO. 


17 


seated  suppuration  is  often  found  to  occur  after  severe  itch- 
ing in  the  part  with  only  erythematous  redness  on  the 
surface. 

Fistula  in  children  almost  always  results  from  worms  or 
injury  to  the  anal  region. 

Fistula,  in  the  majority  of  cases,  commences  by  the  for- 
mation of  an  abscess  immediately  beneath  the  skin  just  out- 
side the  anus;  it  is  generally  said  to  commence  in  the  ischio- 
rectal fossa,  but  I  am  certain  this  is  the  rarer  situation;  it 
may  also  begin  by  ulceration  of  the  mucous  membrane  of 
the  rectum,  as  seen  in  phthisical  patients;  when  it  arises  in 
this  manner  fecal  matter  collects  in  the  connective  tissue, 
and  then  an  abscess  will  form  and  open  outside;  and,  lastly, 
and  abscess  may  form  in  the  sub-mucous  connective  tissue 
of  the  rectum,  and  then  burst  into  the  bowel.  This  is  its 
ordinary  termination,  but  it  may  insidiously  undermine  the 
rectum  in  any  direction,  and  I  am  convinced  that  the  most 
serious  forms  of  fistula  not  uncommonly  originate  in  this 
manner. 

Rectal  abscess  may  arise  rapidly,  when  there  will  be  red- 
ness, tenderness  and  often  very  acute  pain  with  constitu- 
tional disturbance;  or  it  may  be  months  in  formation,  and  be 
perfectly  painless  even  on  manipulation;  the  only  evidence 
of  the  abscess  being  a  flat,  boggy,  crepitating  enlargement, 
which  can  be  felt  at  the  side  of  the  anus.  This  form  of 
abscess  in  the  most  dangerous,  as  it  is  apt  to  be  neglected; 
it  has  little  tendency  to  open  spontaneously,  and  it  results 
in  a  burrowing  up  by  the  side  of  the  rectum  to  some  distance, 
as  well  as  under  the  skin  toward  the  perineum  or  buttock, 
or  both. 

I  think,  on  the  whole,  by  far  the  most  usual  course  is  for 
the  abscess  to  form  rapidly,  with  great  pain,  and  if  not  inter- 
fered with  to  burst  externally  ;  the  patient  then  becomes 
suddenly  easy,  and  fancies  that  his  trouble  is  over.  The 
cavity  of  the  abscess  seldom  entirely  closes,  but  sooner  or 
later  it  contracts,  leaving  a  weeping  sinus  with  a  pouting, 
papillary  aperture,  which  may  be  situated  near  or  far  from 
the  anus. 

It  is  not  often  that  one  sees  a  rectal  abscess  very  early  ; 
either  the  patient  is  not  aware  of  the  importance  of  attend- 
ing to  the  early  symptoms,  or  he  temporizes,  using  fomenta- 
tions or  poultices  ;  or  even  when  seen  by  a  surgeon,  the 
proper  treatment  is  not  always  promptly  adopted.  I  have 
seen  large  abscesses  painted  with  iodine,  under  the  idea  of 
2 


l8  FISTULA   IN    ANO. 

obtaining  absorption.  It  is  well  to  remember  that  as  soon 
as  pus  is  formed,  there  is  only  one  method  of  treatment  to 
be  for  a  moment  entertained,  and  that  is  incision.  It  is  cer- 
tainly less  damaging  to  cut  into  an  inflamed  swelling  near 
the  anus  without  finding  pus  than  to  let  a  day  pass  over  after 
suppuration  has  commenced  ;  the  longer  the  abscess  is  left 
unopened  the  greater  the  danger  of  the  formation  of  lateral 
sinuses.  Before  any  pus  exists,  rest,  warm  fomentations  and 
leeches  may  cut  short  the  attack,  but  such  a  result  is  very 
rare.  Very  small  abscesses  can  be  well  and  easily  opened  in 
the  following  way  :  Place  the  patient  on  the  side  on  which 
the  swelling  exists  ;  pass  the  forefinger  of  the  left  hand,  well 
anointed,  into  the  bowel  ;  then  place  the  thumb  of  the 
same  hand  below  the  swelling  on  the  skin.  Now  make  out- 
ward pressure  with  your  finger  in  the  bowel,  and  you  render 
the  swelling  quite  tense  and  defined,  it  being,  in  fact,  taken 
between  your  finger  and  thumb.  A  curved  bistoury  is  then 
to  be  thrust  well  into  the  abscess,  in  a  direction  parallel  to 
the  long  axis  of  the  bowel,  and  made  to  cut  its  way  out 
toward  the  anus  ;  it  is  well  to  make  a  thoroughly  free  incis- 
ion, commencing  at  the  outermost  part  of  the  swelling.  If 
the  part  be  thoroughly  frozen  by  the  ether  spray,  this  opera- 
tion, otherwise  exquisitely  painful,  may  be  rendered  almost, 
if  not  quite,  painless. 

The  method  of  operating  above  described  is  by  no  means 
suitable  to  a  severe  and  deep-seated  abscess  ;  I  can,  however, 
safely  say  that  if  a  patient  suffering  from  this  latter  form  will 
allow  me  to  act  in  my  own  way,  I  can  almost  guarantee  that 
no  fistula  shall  result.  The  following  is  the  method  to  be 
adopted.  The  patient  must  take  an  anaesthetic,  as  the  opera- 
tion is  very  painful.  I  first  lay  the  abscess,  outside  the  anus, 
open  from  end  to  end,  and  from  behind  forward  /.  e.,  in  the 
direction  from  the  coccyx  to  the  perineum.  I  then  introduce 
my  forefinger  into  the  abscess  and  break  down  any  second- 
ary cavities  or  loculi,  carrying  my  finger  up  the  side  of  the 
rectum  as  far  as  the  abscess  goes,  probably  under  the 
sphincter  muscles,  so  that  only  one  large  sac  remains;  should 
there  be  burrowing  outward,  I  make  an  incision  into  the 
buttock  deeply,  at  right  angles  to  the  first.  I  then  syringe 
out  the  cavity  and  carefully  fill  it  with  wool  soaked  in  car- 
bolized  oil,  one  part  to  ten  or  twelve  ;  this  I  leave  in  for  a 
day  or  two,  then  take  it  out  and  examine  the  cavity,  and 
dress  again  in  the  same  manner,  l3ut  in  addition  I  now  use,  if 
I    think    it    necessary,  one   or  more   drainage    tubes.     In  a 


FISTULA    IN    ANO.  I9 

remarkably  short  time  these  patients  recover  ;  the  sphincters 
have  not  been  divided,  and  the  patient  therefore  escapes  the 
risk  of  incontinence  of  faeces  or  flatus  which  sometimes  occurs 
when  both  the  sphincters  are  deeply  incised.  I  could  cite 
numbers  of  cases  of  very  unfavorable  aspect,  and  in  old 
persons,  that  have  done  quite  well,  treated  as  I  have 
described. 

To  give  your  patient  the  best  possible  chance  of  recovery, 
you  must  keep  him  on  the  sofa,  if  not  in  bed.  I  always  think 
it  advisable  to  clear  out  the  bowels  once,  and  then  confine 
them  by  an  astringent  dose  of  opium  for  three  days  ;  you 
thus  secure  entire  rest  to  the  parts,  and  give  every  opportu- 
nity for  the  cavity  of  the  abscess  to  fill  up.  After  a  time  the 
carbolized  oil  should  be  discarded  and  lotions  used  contain- 
ing nitrate  of  silver,  copper,  zinc,  or  friar's  balsam,  which  last 
does  great  good.  I  find  boracic  acid  ointment,  not  strong, 
or  a  solution  of  thymol,  advantageous  ;  you  must  be  pre- 
pared to  ring  the  changes  ;  but  one  thing  always  remember, 
never  stuff  an  abscess,  but  put  wool  in  very  lightly  and  use 
drainage  tubes  ;  on  the  whole,  I  prefer  the  India  rubber  tube 
to  any  other  contrivance,  and  have  had  the  best  results  from 
it,  as  it  gives  rise  to  no  pain,  an  advantage  which  cannot  be 
claimed  for  either  the  wire  tube  or  the  horsehair. 

The  questions  naturally  arise.  Why  do  these  abscesses 
usually  fail  to  close  up  ?  Why  do  they  form  sinuses  ?  There 
are  doubtless  several  reasons,  but  the  following  may  be  suffi- 
cient. The  mobility  of  the  parts,  caused  by  action  of  the 
bowels  and  movemant  of  the  sphincter  muscles,  almost  at 
every  breath,  and  the  presence  of  much  loose  areolar  tissue  and 
fat.  The  vessels  also  near  the  rectum  are  not  well  supported, 
and  the  viens  have  no  valves  ;  there  is  therefore  tendency  to 
stasis,  and  this  is  inimical  to  rapid  granulation.  We  know 
that  abscesses  are  always  apt  to  degenerate  into  sinuses 
when  situated  in  any  lax  areolar  tissue,  as  in  the  axilla,  neck, 
or  groin. 

After  an  abscess  has  long  existed  the  discharge  loses  its 
purulent  character  ;  it  becomes  watery  ;  the  abscess  has 
gradually  contracted,  and  now  only  a  sinus,  very  often 
formed  of  dense  tissue,  remains.  If  the  sinus  be  laid  open, 
you  may  observe  that  its  interior  resembles  in  appearance 
the  inner  coat  of  an  artery,  so  glistening  and  smooth  has  it 
become.  This  was  formerly  called  a  pyogenic  membrane  ; 
it  certainly  secrets  pus,  but  it  is  not  a  membrane. 

If  now  a  probe  be  passed  very  tenderly  into  this  sinus. 


20  FISTULA    IN    ANO. 

allowing  it  to  follow  its  own  course,  and  after  this  is  done, 
the  finger  be  placed  in  the  rectum,  you  will  probably  find 
that  the  probe  has  traversed  the  sinus,  passed  through  an 
internal  opening,  and  can  be  felt  in  the  bowel.  In  this  case 
you  would  have  a  typical,  simple  complete  fistula  ;  and  this 
is  by  far  the  most  common  variety,  very  few  fistulae  that 
have  existed  for  more  than  three  months  being  without  an 
internal  opening. 

Besides  this  common  form  there  are  two  other  descriptions 
of  fistula,  viz.,  the  blind  external  fistula,  and  the  blind  inter- 
nal fistula.  In  the  blind  external  fistula  there  is  an  external 
opening,  and  it  is  therefore  called  an  external  fistula,  but  no 
internal  opening,  hence  "a  blind  external."  In  the  other 
variety  there  is  and  internal  opening,  consequently  it  is  an 
internal  fistula,  and  there  is  no  external  opening,  therefore 
it  must  be  called  a  blind  internal  fistula. 

I  have  so  often  seen  confusion  in  the  use  of  these  terms 
that  I  have  been  particular  in  describing  them  ;  and  consid- 
ered in  the  way  I  have  put  it,  I  think  there  can  be  no  mis- 
conception. 

The  blind  internal  form  of  fistula  results  usually  from 
some  injury  to,  or  ulceration  of,  the  lining  membrane  of  the 
rectum,  or  abscess  in  the  connective  tissue  beneath  the 
mucous  membrane,  and  is  most  commonly  found  in  subjects 
who  have  consumption  or  who  are  predisposed  to  it. 

Now,  these  terms,  "  complete,"  "  blind  external,"  and 
**  blind  internal,"  are  useful,  but  suigically  they  are  of 
little  moment  ;  there  is  a  very  much  more  inportant  divis- 
ion which  affects  the  character  of  the  fistula  as  regards  its 
seriousness  to  the  patient  and  also  to  the  surgeon,  I  mean 
the  division  into  anal  fistula  and  pelvic  or  rectal  fistula.  An 
anal  fistula  is  one  which,  commencing  on  the  skin  a  few 
lines  from  the  margin  of  the  anus,  opens  just  inside  the 
orifice,  passes  at  most  under  a  few  fibres  of  the  external 
sphincter,  and  is  trivial  and  can  be  rapidly  and  safely  cured. 
By  pelvic  or  rectal  fistula  I  mean  a  fistula  which,  commenc- 
ing probably  by  an  abscess  in  the  ischio-rectal  fossa,  passes 
underneath  both  the  spliincter  muscles  and  opens  possibly 
high  up  in  the  bowel,  indeed,  in  the  pelvis.  This  is  the 
fistula  which  is  dangerous  lo  the  patient,  and  will  call  forth 
all  the  knowledge  and  experience  of  the  surgeon  to  bring  to 
a  successful  issue.  My  friend,  Dr.  David  Molliere,  of  Lyons, 
in  his  exceedingly  exhaustive  and  able  work  on  "  Diseases  of 
the  Rectum,"  makes  practically  the  same   division,  calling 


FISTULA    IN   ANO.  21 

the  first  "  Fistules  sous-tegumentaires,"  and  the  second 
*'  Fistules  sous-musculaires." 

We  will  now  imagine  that  you  have  a  fistulous  patient 
before  you.  Proceed  to  examine  him  thus:  Place  him  upon 
a  hard  couch,  on  the  side  upon  which  the  disease  is  supposed 
to  be  situated,  the  buttocks  being  brought  close  to  the  edge 
of  the  couch,  and  the  knees  drawn  up.  Look  at  the  anus 
and  the  surrounding  parts  carefully,  to  detect  any  visible 
malady.  You  may  see  the  orifice  of  a  sinus,  or  some  dis- 
coloration of  the  skin  may  show  you  the  site  of  the  disease. 
Then  feel  gently  all  around  the  anus  with  the  forefinger,  and 
you  will  often,  by  the  induration,  detect  the  course  and 
position  of  the  sinus,  which  feels  like  a  pipe  beneath  the 
skin.  Having  satisfied  yourself  in  these  respects,  pass  the 
probe  into  the  external  aperture;  hold  the  probe  with  a  very 
light  hand,  and  let  it  almost  find  its  own  way.  In  many 
cases,  as  I  have  before  said,  it  will  pass  right  into  the  bowel; 
when  the  probe  has  been  passed  as  far  as  it  will  go  without 
using  any  force,  introduce  the  forefinger  of  the  left  or  right 
hand,  whichever,  according  to  the  position  of  the  patient,  is 
most  convenient,  into  the  rectum;  do  not,  as  is  often  done, 
introduce  your  finger  before  the  probe;  if  you  do,  you  will 
excite  contraction  of  the  sphincter,  and  the  sinus  will  be 
drawn  up  or  contorted,  and  consequently  the  passage  of  the 
probe  is  obstructed.  When  the  finger  is  in  the  bowel,  if  the 
probe  has  not  come  through  the  internal  orifice,  feel  for  the 
opening — an  educated  digit  will  nearly  always  detect  it;  and, 
having  found  the  opening,  you  can  with  the  other  hand 
guide  the  probe  toward  it. 

The  internal  aperture  is  usually  situated  just  within  the 
anus,  in  the  depression  which  exists  between  the  external 
and  internal  sphincters.  I  do  not  say  that  it  is  by  any  means 
invariably  so  placed,  but  I  am  sure  that  this  is  its  common 
situation;  and  one  reason  why  the  opening  is  not  felt  when 
the  finger  is  inserted  is  because  the  search  for  it  is  made  too 
high  up  the  bowel. 

I  think  the  reason  the  internal  opening  is  situated  so  often 
in  the  position  I  have  named,  is  this:  The  abscess  forming, 
in  most  cases,  just  outside  the  anus,  does  not  burrow  deeply, 
but  passes  close  under  the  external  sphincter;  it  then  is 
prevented  from  ascending  higher  up  the  bowel  by  the  thick 
band  of  the  internal  sphincter,  and  consequently  is  turned 
inward,  and  makes  its  way  through  the  lax  areolar  tissue,  in 
the    space   between   the    two   muscles.     When  the  abscess 


22  FISTULA    IN    ANO. 

really  commences  in  the  ischio-rectal  fossa,  it  burrows  deeply, 
and  then  most  usually  passes  beneath  the  internal  sphincter, 
and  opens,  if  at  all,  high  up  in  the  rectum. 

Occasionally  more  than  one  internal  opening  exists,  and 
I  have  now  many  times  seen  what  the  late  Mr.  Syme  declared 
could  not  occur,  viz.,  two  internal  openings  in  the  same 
patient  at  the  same  time;  at  St.  Mark's  I  recently  treated  a 
case  in  which  there  was  an  internal  aperture  at  each  side  of 
the  bowel. 

It  is  all-important  that  this  internal  aperture  be  felt  with 
the  finger  (so  that  in  operating  it  may  be  included  in  your 
incision),  for  not  unfrequently,  from  the  tortuous  nature  of 
the  fistula,  the  probe  cannot  readily  be  got  through  it;  this 
is  markedly  the  case  in  the  horse-shoe  form  of  fistula,  which 
is  not  uncommon.  The  sinus  here  runs  round,  generally 
dorsally,  from  one  side  of  the  anus  to  the  other,  so  that  the 
external  and  internal  openings  are  placed  on  opposite  sides 
of  the  bowel.  This  variety,  if  not  properly  diagnosed,  is 
rarely  cured  by  operation,  the  sinus  being  laid  open  on  one 
side  of  the  bowel,  and  left  untouched  on  the  other;  this 
mistake  may  generally  be  avoided  by  a  careful  examination 
with  the  finger  externally,  as  you  can  feel  a  hardness  on  both 
sider  of  the  anus;  the  patient  will  also  sometimes  assist  you 
by  telling  you  that  he  has  felt  something  like  a  "  piece  of 
wire  "  on  both  sides  of  the  bowel. 

When  you  pass  your  finger  into  the  bowel  to  search  for 
the  internal  opening,  never  forget  to  carry  it  higher  up,  to 
see  if  the  rectum  be  otherwise  healthy;  you  may  find  stric- 
ture, ulceration,  or  malignant  disease  co-existent;  without 
this  precaution  these  conditions  may  be  overlooked. 

A  fistula  may  be  a  very  trivial  matter  indeed,  which  you 
can  operate  upon  in  the  out-patients'  room,  and  send  your 
patient  home  afterwards,  or  it  may  be  a  really  serious  affair, 
demanding  extensive  surgical  interference.  I  have  often 
seen  a  buttock  so  riddled  with  sinuses  as  to  resemble  a 
miniature  rabbit-warren  more  than  anything  else. 

Fistula  may  exist  for  years  without  causing  much  pain  or 
inconvenience  to  the  patient.  I  have  met  with  many  persons 
who  have  had  rectal  sinuses  for  ten  years  and  upward,  and 
never  had  anything  more  done  than  the  occasional  passing 
of  the  probe  when  the  external  aperture  got  blocked  up,  and 
pain  was  caused  by  the  formation  and  retention  of  matter. 

When  the  tissues  c.round  the  sinus  become  very  dense 
there  may- be,  for  a  long  period,  an  arrest  of  burrowing,  but 


FISTULA    IN    ANO.  2$ 

an  attack  of  inflammation  set  up  at  any  time  will  cause  a 
fresh  abscess. 

When  seeking  to  determine  whether  you  can  safely  leave 
a  fistula  for  a  time,  the  nature  of  the  case  is  an  import- 
ant element  for  consideration.  The  blind  external  hstula  is 
the  safest  to  leave.  An  internal  fistula  with  a  large  internal 
opening,  and  the  sinus  running  from  it  toward  the  anus,  is 
sure  to  burrow,  because,  being  funnel-shaped,  with  the 
larger  end  of  the  funnel  upward,  faeces  readily  pass  into  it 
and  inflammation,  much  pain,  and  extension  of  the  disease 
will  certainly  ensue. 

Usually  it  may  be  said  the  longer  a  fistula  is  left  the  more 
does  it  burrow,  and  the  more  difficult  it  is  of  cure;  therefore 
I  think  it  unwise  to  tell  a  person  to  have  nothing  done  as 
long  as  he  is  not  suffering — advice  which  I  frequently  hear 
is  given  to  patients. 

I  am  often  anxiously  asked  by  sufferers  if  a  fistula  can  be 
cured  without  an  operation,  or,  as  they  say,  "  the  use  of  the 
knife."  To  this  I  reply  that  I  have  seen  all  kinds  of  fistula 
get  well,  with  and  even  without  treatment,  but  these  occur- 
rences are  quite  exceptions  to  the  rule,  and  should  not  be 
depended  upon;  still,  if  the  fistula  be  simple,  and  the  patient 
be  unwilling  to  submit  to  any  operation,  certain  methods 
may  fairly  be  tried.  For  the  last  few  years,  I  have  been 
successful,  on  many  occasions,  in  curing  blind  external,  and 
even  complete  fistulse,  by  means  of  carbolic  acid  and  drainage 
tubes.  This  mode  of  treatment,  if  carried  out  with  great  care, 
and  some  perseverance,  offers,  in  my  opinion,  the  best  chance 
for  the  patient.  I  find  it  is  essential  that  the  outer  opening 
of  the  fistula  should  be  much  dilated  before  applying  the 
acid  or  using  tubes.  The  dilatation  can  be  accomplished  by 
keeping  in  a  small  portion  of  sea-tangle  for  a  few  days,  or 
by  a  small  sponge  tent.  When  the  opening  is  large  enough, 
I  clean  out  the  sinus  well,  and  then  rapidly  run  down  to  the 
end  of  it  a  small  piece  of  wool  saturated  in  strong  carbolic 
acid  with  ten  per  cent,  of  water.  I  mount  the  wool  upon  a 
stiff  piece  of  wire  set  in  a  handle  and  just  roughened  at  the 
free  end.  The  wool  can,  with  a  little  practice,  be  wound 
tightly  on  the  end  of  the  wire  so  as  to  be  small  enough  to  go 
right  to  the  bottom  of  the  sinus.  I  then  withdraw  the  wire 
and  put  in  a  drainage  tube  just  large  enough  to  fill  the  sinus 
and  keep  it  in;  the  interior  of  the  sinus  is,  by  the  acid, 
induced  to  granulate,  and  if  you  are  successful,  you  will  find 
almost   day  by  day,    that  a  shorter  drainage  tube  will  be 


24  FISTULA    IN    ANO. 

required  until  the  whole  sinus  is  filled  up.  It  may  be 
necessary  to  apply  the  acid  more  than  once,  and  to  use  other 
stimulants,  as  Friar's  balsam,  solutions  of  sulphate  of  copper, 
or  nitrate  of  silver,  etc.,  but  never  strong  injections;  care 
should  always  be  taken  to  keep  the  external  opening  well 
dilated.  I  had  thought  the  heated  galvanic  wire  passed  to 
the  bottom  of  a  sinus  would  be  very  effectual,  but  many 
trials  have  convinced  me  that  it  cannot  be  relied  on,  and 
that  it  causes  much  pain. 

I  have  now  seen  many  spontaneous  cures  of  simple  fis- 
tula, and  have  also  seen  an  ordinary  examination  with  a  probe 
set  up  exactly  the  quantity  of  inflammation  required  to 
obliterate  the  sinus,  and  a  good  many  of  such  results  I  have 
had  opportunities  of  watching,  and  no  return  has  taken 
place  ;  but,  on  the  other  hand,  the  bulk  of  the  so-called 
spontaneous  cures  are  illusory,  and  the  disease  returns  in 
time,  and  even  the  same  may  be  said  of  those  in  which  treat- 
ment, short  of  division,  has  seemed  effectual.  In  my  opin- 
ion, there  is  nothing  equal  to  the  division  of  the  fistula  and 
getting  it  to  fill  up  soundly  from  the  bottom. 

I  will  relate  a  few  cases  of  spontaneous  cure,  and  also  an 
example  or  so  of  cure  by  treatment,  which  have  recently 
occurred  in  my  practice. 

Spontaneous  Cure  of  a  Bli7id  External  Fistula. — ^Wm. 
B — ,  3et.  49,  a  draper's  assistant,  admitted  into  St.  Mark's 
August  30th,  1864.  Had  an  abscess  five  months  ago,  by  the 
side  of  the  anus,  which  was  opened,  and  ever  since  there  has 
been  a  discharge  from  it;  at  times  it  is  very  sore  and  swells, 
then  it  breaks  and  discharges  again,  and  he  is  quite  comforta- 
ble. On  examination  a  blind  external  fistula  was  found, the  ori- 
fice being  close  to  the  external  edge  of  the  sphincter;  the  sinus 
ran  up  quite  an  inch,  and  did  not  approach  near  to  the 
mucous  membrane.  I  was  quite  sure,  from  a  most  careful 
examination,  that  no  internal  aperture  existed. 

No  treatment  was  adopted,  as  I  intended  to  take  him  in 
when  there  was  a  vacant  bed.  He  only  had  a  little  calomel 
ointment  ordered,  and  a  pill,  to  keep  the  bowels  acting.  In 
three  weeks  he  told  me  the  sinus  had  healed,  and  on  exami- 
nation I  found  it  to  be  so.  Of  course,  I  expected  it  to 
break  out  again 

October  nth.  It  remains  soundly  healed,  and  the  hard- 
ness is  fast  disappearing. 

December  20th.  The  fistula  remains  quite  well;  there  is 
no  evidence  now  of  where  it  was,   no  mark   of  the  original 


FISTULA  IN    ANO. 


25 


aperture,  and  no  induration.  My  opinion  is  that  the  prob- 
ing in  this  case  was  just  sufficient  to  set  up  granulation  and 
rapid  closure  of  the  sinus.  It  did  not  return,  I  am  sure,  as 
the  man  would  certainly  have  come  to  me,  being  so  delighted 
with  the  result  of  what  he  considered  my  skillful   treatment. 

Blind  External  Fistula  j  Spontaneous  Cure. — J.  C. — , 
aet.  46,  a  porter  at  the  Tilbury  Station;  admitted  into  St. 
Mark's,  May,  1867.  Steady  man;  suffers  from  ague.  Six 
months  ago  had  a  rectal  abscess,  which  burst,  and  has  con- 
tinued to  discharge  more  or  less  up  to  the  present  time.  A 
sinus  was  found  running  some  distance  up  by  the  bowel, 
rather  deeply  situated,  and  not  communicating,  I  wished  to 
take  him  in,  but  he  said  he  could  not  lay  up  yet.  Ordered 
a  mild  aperient,  and  some  zinc  ointment.  In  a  fortnight  he 
came  again,  and  said  the  fistula  had  healed.  I  examined 
him,  and  found  it  closed;  moreover,  it  was  not  tender. 

June  7th.  Again  examined;  found  it  still  well;  no  pain; 
very  little  hardness;  no  discharge  from  the  bowel;  and  I 
explored  the  rectum  to  see  if  it  could  have  opened  inter- 
nally, but  this  was  not  the  case. 

July.  Saw  him  again,  and  he  was  quite  well,  and  has  con- 
tinued so.  I  believe  he  has  never  had  any  return  of  this 
malady. 

Bli?zd  External  Fistula;  Spontaneous  Cure. — Jas.  L. — , 
aet.  65,  came  to  St.  Mark's,  July  5th,  1864.  The  external 
aperture  was  some  distance  from  the  anus;  the  sinus  passed 
up  beyond  the  external  sphincter,  and  the  probe  could  be 
felt  rather  nearer  the  mucous  membrane.  No  particular 
treatment.  The  probe  was  passed  again  in  about  a  fort- 
night after  he  was  first  seen.  The  sinus  healed  up  while  he 
was  waiting  his  turn  to  come  in.  I  kept  him  under  observa- 
tion until  the  end  of  December,  when,  finding  no  return  of 
the  fistula,  no  pain,  no  discharge,  no  internal  opening,  no 
hardness  in  the  old  track  of  the  sinus,  I  discharged  him  as 
cured. 

Complete  Fistula  in  Ano  ;  Spontaneous  Cure. — W.  H. 
K. — set.  30,  clerk,  admitted  into  St.  Mark's,  April  2d,  1867. 
Not  yery  strong;  habits  regular.  On  examination  a  small 
but  complete  fistula  was  found  on  the  right  side  of  the  anus, 
the  external  opening  being  quite  an  inch  from  it,  the  inter- 
nal aperture  being  in  the  usual  place  between  the  two  sphinc- 
ters. In  the  middle  of  May  I  took  him  in  as  an  in-door 
patient,  and  on  going  to  operate  I  found  the  external  orifice 
so   firmly   closed  that   I  cauld   not   without   unwarrantable 


26  FISTULA    IN    ANO. 

force  get  a  probe  into  it;  I  could  feel  the  internal  aperture 
very  small.  There  was  no  pain,  so  I  left  him.  Next  week 
I  asrain  examined  him,  and  found  the  internal  orifice  also 
closed.  I  kept  him  in  the  hospital  another  week,  and  still 
the  fistula  remained  healed,  so  I  put  him  upon  the  out- 
patient list,  and  he  attended  up  to  the  end  of  August,  when, 
finding  the  fistula  still  closed,  and  there  being  no  pain  and 
no  induration,  I  discharged  him  as  cured,  requesting  him  to 
come  again  immediately  on  any  return  of  pain  or  swelling. 
I  have  not  seen  him  since. 

Most  of  the  cases  of  fistula  which  I  have  tried  to  cure 
without  an  operation  have  occurred  in  private  practice;  the 
reason  is,  that  time  is  generally  a  great  consideration  to  the 
poor  man;  he  does  not  mind  a  little  pain;  he  wants  to  be  cured 
as  quickly  as  possible,  and  therefore  prefers  to  be  operated 
upon  at  once;  in  order  to  get  well  certainly  and  speedily.  It 
is  only  the  rich  who  can  afford  the  luxury  of  three  or  four 
months'  treatment,  finding  themselves  perhaps,  at  the  end  of 
that  time,  in  much  the  same  condition  as  they  were  at  its 
commencement.  Altogether  I  find  that  I  have  had  twenty- 
one  successful  cases,  and  a  considerable  number  in  which  I 
have  failed  to  effect  a  cure  after  a  prolonged  attempt,  there- 
fore I  cannot  say  the  prospect  is  very  encouraging,  but 
patients  who  will  not  submit  to  the  knife  will  often  allow  me 
to  use  the  elastic  ligature,  and  of  that  I  shall  have  more  to 
say  presently. 

CASES   CURED    BY    TREATMENT. 

A  gentleman,  set.  50,  a  free  liver  and  very  nervous,  came 
to  me  with  a  blind  external  fistula  on  the  right  side,  January 
9th,  1875.  I  could  hardly  examine  him,  in  consequence  of 
his  terror,  so  I  ordered  him  some  sedative  ointment,  and 
requested  him  to  come  again  m  three  days.  He  was  on  his 
second  vi&'t  less  timorous,  and  I  made  out  that  he  had  an 
anal  fistula  of  the  blind  external  kind.  I  advised  division, 
first  by  knife,  then  by  the  elastic  ligature,  but  he  turned  a 
deaf  ear  to  all  I  could  say.  Cut  or  tied  he  would  not  be. 
The  experience  of  Louis  XIV  was  nothing  to  him,  and  he 
thought  very  disparagingly  of  an  art  which  could  do  no  bet- 
ter than  cut  people.  He  readily  assented  to  my  making 
trial  of  any  treatment  not  very  painful,  so  I  dilated  the 
opening  with  sponge  tent,  and  then  wiped  the  sinus  thor- 
oughly with  the  carbolic  acid.  The  pain  was  trivial,  only 
slight'burning  for  a  few  minutes.      After  twenty-four  hours 


FISTULA    IN    ANO.  2J 

I  put  in  a  small  india-rubber  drainage  tube.  He  went  about 
as  usual,  but  the  bowels  I  kept  confined  for  six  days.  At 
the  end  of  that  time  a  copious  enema  of  oil  and  gruel  thor- 
oughly relieved  him.  The  discharge  from  the  fistula  had 
been  gradually  diminishing,  and  the  sinus  was  much  less 
deep.  All  I  now  did  was  to  keep  the  external  opening  wide 
by  a  piece  of  sponge,  and  in  three  months  the  sinus  was 
quite  healed.  I  have  good  reason  to  know  that  this  case 
was  a  genuine  success, 

A  gentleman  set.  40,  robust,  but  wonderfully  cowardly, 
came  to  see  me  on  the  26th  of  June,  1875.  ^^  examina- 
tion showed  a  small,  blind  external  fistula.  He  had  suffered 
from  abscess  near  the  rectum,  which  a  gentleman  opened 
for  him  nine  months  ago,  and  the  pain  he  had  gone  through 
from  that  was  such  as  to  make  him  determine  that  nothing 
should  persuade  him  to  be  cut  again.  I  immediately  pro- 
posed the  elastic  ligature,  in  which  I  assured  him  I  had 
great  confidence;  but  unfortunately  he  had,  before  seeing 
me,  consulted  a  surgeon,  who  related  to  him  an  awful  case 
he  had  experienced  with  the  ligature,  which  did  not  come 
away  for  nine  days,  during  which  time  the  patient  was  in 
incessant  pain.  So  he  would  have  none  of  it.  I  dilated  the 
external  opening  with  the  tangle,  and  then  put  in  a  drainage 
tube,  but  did  not  use  carbolic  acid  or  any  strong  applica- 
tion, as  the  patient  feared  pain.  For  some  time  this  case 
did  not  do  well,  and  I  was  on  the  point  of  giving  it  up, 
when  I  persuaded  him  to  take  an  anaesthetic  and  allow  me 
to  dilate  his  sphincter  muscles  (which  were  very  spasmodi- 
cally contracted),  and  apply  the  carbolic  acid.  He  con- 
sented; and  the  result  of  this  combined  attack,  and  keeping 
him  in  bed  a  week,  conquered  the  sinus,  and  it  healed 
rapidly.     I  fancy  this  patient  has  remained  well. 

A  difficulty  in  these  cases  is  to  keep  the  external  orifice 
very  large  without  irritating  too  much  ;  and  my  friend  Mr. 
Clover,  with  his  usual  ingenuity,  effected  that  object  wonder- 
fully well  in  a  case  I  saw  with  him,  by  inserting  a  bone  col- 
lar stud  into  the  opening.  When  this  was  slipped  in,  it 
remained  fixed,  and  the  patient  wore  it  and  went  about 
without  complaining  even  of  discomfort;  since  seeing  this 
case  I  have  tried  the  collar  stud  on  many  occasions,  but  have 
had  a  small  hold  drilled  through  from  end  to  end,  in  order 
that  no  pus  might  be  retained  in  the  sinus,  and  it  has  ans- 
wered the  purpose  I  desired,  viz.,  to  keep  the  external  ori- 
fice large. 


28     FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE. 

A  lady  came  to  me  from  the  country,  in  the  beginning  of 
1879,  with  a  small  abscess,  which  had  been  opened,  and  a 
sinus  running  up  the  bowel  for  quite  an  inch.  She  was  most 
desirous  to  be  cured,  but  would  not  have  the  knife,  and 
feared  the  elastic  ligature.  I  was  able,  after  a  little  dilatation 
of  the  orifice,  to  get  the  bone  stud  in,  and  in  ten  days  the 
sinus  had  healed.  To  give  her  every  chance  she  kept  her 
soia,  and  I  confined  the  bowels  for  seven  days.  I  saw  this 
patient  recently,  and  she  kept  quite  well. 

Since  the  publication  of  my  last  edition  I  have  cured 
many  patients  by  dilatation  of  the  sphincters  and  the  use  of 
the  bone  stud  and  carbolic  acid.  I  do  not  think  anything 
would  be  gained  by  relating  more  cases.  One  practical 
point  I  would  mention.  The  further  the  external  aperture 
is  from  the  sphincter  the  more  likelihood  is  that  the  sinus 
may  heal.  This  is  shown  as  well  in  the  cases  of  spontane- 
ous cure  as  in  my  own  successes.  It. is  very  important,  in 
these  attempts,  not  to  do  any  harm.  You  must  always 
enjoin  rest  after  a  strong  application,  and  watch  that  not 
too  much  inflammation  be  set  up. 


CHAPTER  IV. 

FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE. 

As  I  have  been  considering  the  treatment  of  fistula  with- 
out cutting,  I  think  before  describing  the  usual  methods  of 
operating,  I  had  better  relate  my  experience  of  the  use  of  the 
elastic  ligature,  describe  its  mode  of  application,  and  endea- 
vor to  point  out  what  really  it  can  do  and  what  it  cannot  be 
expected  to  do.  And  at  once  I  will  fully  confess  that  when 
I  read  a  paper  before  the  Medical  Society  of  London,  in 
February,  1875,  on  the  treatment  of  fistula  and  other  sinuses 
by  the  elastic  ligature,  I  anticipated  a  wider  use  for  it  than 
I  have  found.  Still,  I  must  assert  that  the  ligature  is  most 
valuable  in  many  cases,  and  frequently  invaluable  as  an 
auxiliary  to  the  knife. 

Professor  ]  >ittel,  of  Vienna,  may  certainly  be  called  the 
apostle  of  the  elastic  ligature,  but  he  was  not  the  discoverer, 
as  Mr  Henry  Lee  and  also   Mr,  Holthouse  had  previously 


FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE.      29 

used  it  for  the  removal  of  naevi  and  in  anal  fistulas.  When 
I  read  Professor  Dittel's  paper  I  came  to  the  conclusion  that 
the  indian-rubber  ligature  might  be  found  very  useful  in  the 
brance  of  surgery  to  which  I  had  paid  special  attention.  I 
therefore  determined  to  make  a  fair  trial  of  it,  and  have  now 
employed  it  in  more  than  150  varied  cases.  I  can  truly  say 
I  have  over  and  over  again  been  very  glad  that  the  utility 
of  the  elastic  ligature  had  been  brought  forward  by  Profes- 
sor Dittel  after  it  had  quite  fallen  into  oblivion. 

Ligatures  of  thread  have  been  employed  for  a  great  many 
years,  even,  we  may  say,  from  the  time  of  Ambrose  Pare,  for 
cutting  through  certain  structures,  mainly  arteries ;  but 
haemorrhoids,  naevi,  warty  and  pedunculated  growths  have 
constantly  been  removed  by  the  application  of  a  ligature, 
and  the  reason  it  has  not  been  removed  by  the  application 
of  a  ligature,  and  the  reason  it  has  not  been  more  extensively 
available  has  arisen  from  the  fact  that  only  a  comparatively 
limited  thickness  of  tissue  can  be  cut  through  by  one  appli- 
cation of  the  ligature,  which,  as  suppuration  takes  place, 
becomes  loose,  and  then  does  not  penetrate  further  unless  it 
be  re-tightened;  it  is  therefore  only  small  and  soft  growths 
that  can  be  safely  and  advantageously  treated  by  the  inelastic 
thread  ligature. 

Various  means  have  been  devised  to  overcome  this 
inherent  defect,  and  make  the  thread  ligature  cut,  by  con- 
stantly Oi  frequently  tightening  the  thread;  such  means  are 
shown  in  Ricord's  instrument  for  the  treatment  of  varicocele; 
Mr.  Luke's  double  screw,  which  he  invented  for  cutting 
through  rectal  fistulse  which  ran  so  high  up  the  bowel  as  to 
be  considered  dangerous  of  division  with  the  knife.  A 
variety  of  methods,  of  which  a  spiral  spring  is  the  essential 
have  also  been  employed,  from  a  wooden  spiral-spring  letter- 
clip  up  to  the  very  ingenious  sarcotome  of  Dr.  Ainslie 
Hollis. 

To  all  these  methods,  comparatively  good  as  they  may  be, 
some  very  strong  objections  may  be  raised.  From  consider- 
able experience,  I  know  that  Mr.  Luke's  double  screw, 
advantageous  as  it  has  proved,  causea  very  intense  pain;  the 
daily  or  frequent  necessity  for  tightening  the  ligature  inflicts 
upon  the  patient  a  torture  often  unendurable,  and  on  many 
occasions  the  knife  has  had  to  complete  what  the  ligature 
began,  the  patient  being  unable  to  endure  the  long-continued 
suffering.  Another  very  grave  objection  to  the  intermitting 
application  of  pressure  is  the  frequency  with  which  secondary 


30     FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE. 

abscesses  result.  I  have  noticed  this  result  in  my  own  practice, 
and  seen  it  also  in  that  of  other  surgeons. 

Dr.  Hollis's  sarcotome  is  very  superior  to  the  others  in 
action,  but  even  this  requires  tightening  or  re-setting  from 
time  to  time  ;  it  acts  likewise  only  in  one  direction,  and 
therefore  lacks  the  even,  circular  pressure  exerted  by  the 
india-rubber.  Another  important  objection  is  its  size  and 
weight,  which  render  it  under  many  conditions  inapplicable. 

It  must  be  evident,  on  reflection,  that  the  pressure  of  the 
india-rubber  band  or  loop  is  not  always  the  same  during  all 
the  progress  of  the  cutting,  in  fact,  it  diminishes  gradually 
as  the  loop  of  the  ligature  becomes  less  in  circumference  ; 
but  practically  the  pressure  up  the  moment  of  separation, 
if  the  loop  be  properly  adjusted  at  first,  is  sufficient  for  its 
work. 

The  greatest  pressure  exerted  by  a  solid  india-rubber  liga- 
ture of  the  thickness  of  yV^b  of  an  inch,  stretched  to  the 
utmost,  only  equals  2^  lbs.  weight;  for  example,  6  inches  of 
india-rubber,  when  stretched  to  its  utmost,  /.  e.  3  feet,  exer- 
cises a  power  of  2^  lbs.;  when  stretched  to  2  feet  only  a 
little  more  than  i;^  lbs.;  and  when  stretched  only  i  foot,  or 
double  its  length,  -|-  lb.;  and  even  this  power  is  quite  suffi- 
cient, as  shown  by  experiment,  to  pass  through  any  ordinary 
tissue,  in  consequence  of  its  unremitting  and  even  pressure 
in  every  direction. 

I  have  for  a  long  time  now  used  only  solid  india-rubber, 
so  strong  that  I  cannot  break  it ;  and  I  put  it  on  as  tightly 
as  I  can  and  fasten  it  by  means  of  a  small  pewter  clip  pressed 
together  by  strong  forceps.  The  ligature  cuts  through  in 
about  six  days,  z.  e.  that  was  the  average  time  in  ninety  cases 
of  fistula.  The  shortest  time  has  been  three  days,  and  the 
longest  fourteen  days,  and  in  the  latter  case  a  solid  portion 
of  flesh,  three  inches  in  length  and  two  inches  in  thickness, 
was  cut  through  without  any  tightening  of  the  ligature.  You 
may  be  assured  that  those  who  find  a  difficulty  in  getting  the 
ligature  to  cut  quickly  and  painlessly  are  ignorant  of  the 
proper  method  of  applying  it. 

What  are  the  advantages  of  the  ligature  ?  Briefly  these, 
that  in  simple  cases  there  is  little  or  no  pain  inflicted  by  the 
operation  ;  the  patient  can  walk  about  without  danger.  I 
have  had  many  cases  proving  that  nervous  persons  will  often 
submit  to  the  ligature  when  they  will  not  to  the  knife.  There 
is  no  bleeding — a  manifest  advantage  in  dealing  with  patients 
whose  tissues  bleed  copiously  on  incision.     I  have  found  it 


FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE.     3I 

useful  in  several  such  cases.  In  phthisical  cases  it  is,  in  my 
opinion^  the  best  means  of  dividing  a  sinus.  In  very  deep 
bad  fistulae  the  elastic  ligature  is  most  valuable  as  an  auxil- 
iary to  the  knife.  I  now  most  frequently  use  it  in  this  way, 
avoiding  haemorrhage,  in  sinuses  running  high  up  the  bowel, 
where  large  vessels  are  inevitably  met  with.  I  have  recently 
had  many  examples  of  this,  and  have  readily  and  painlessly 
divided  vascular  structures  without  any  danger  of  bleeding. 
In  an  unusually  bad  case  sent  me  by  Dr.  Wm.  Price,  of  Mar- 
gate, a  timid  lady  did  not  know  the  ligature  had  been  used 
until  it  came  away,  on  the  seventh  day,  as  she  had  absolutely 
suffered  no  pain  worth  complaining  about,  and  certainly  not 
more  than  when  the  knife  is  used  alone.  I  have  now  oper- 
ated on  eight  medical  men,  and  they  all  have  told  me  that 
there  had  been  no  pain,  and  even  very  little  discomfort,  from 
the  ligature,  and  it  had  been  a  great  advantage  to  them,  as 
they  were  able  to  get  about  in  a  moderate  way  and  see  their 
patients.  One  mistake  committed  by  those  who  oppose  the 
use  of  the  ligature  is  this  :  they  think  the  wound  does  not 
commence  healing  unt  1  the  ligature  has  come  away;  nothing 
is  further  from  the  truth.  When  the  ligature,  if  it  has  been 
well  applied,  has  cut  its  way  out,  the  wound  is  often  very 
nearly  healed.  I  beg  to  refer  my  readers  to  a  monograph 
by  Professor  Courty,  of  Montpellier,  in  corroboration  of  my 
statement.  This  gentleman  has  used  the  elastic  ligature  fre- 
quently, and  has  been  most  successful.  Now,  what  is  the 
great  objection  to  the  general  use  of  the  ligature  in  fistula  ? 
It  is  this.  It  is  very  difficult,  or  even  impossible  in  many 
instances,  to  be  absolutely  sure  that  only  one  sinus  exists. 
If  there  are  lateral  sinuses,  or  a  sinus  burrovv'ing  beneath  or 
higher  up  the  rectum  than  the  main  trunk  through  which 
you  pass  your  ligature,  the  patient  will  not  get  well  at  one 
operation.  In  these  complicated  cases  the  knife  alone,  or 
conjoined  with  the  ligature,  is  the  only  trustworthy  remedy. 
So  it  comes  about  that  surgeons  not  very  au  fait  in  the  diag- 
nosis of  fistula  soon  get  into  trouble,  and  at  once  condemn 
and  throw  aside  the  ligature. 

I  had  employed  the  india-rubber  ligature  in  only  a  very 
few  cases  before  I  came  to  the  conclusion  that  if  I  intended 
operating  frequently,  or  if  ever  the  method  were  to  become 
popular,  other  and  better  means  than  those  recommended 
and  used  by  Professor  Dittel  must  be  devised  for  the  intro- 
duction of  the  ligature  through  the  fistula.  Professor  Dittel 
has  described  several  ways  of  accomplishing  the  end  in  view; 


32     FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE. 


all  of  them  appeared  to  be  theoretically  imperfect,  and  I 
found  them  in  practice  difficult  of  performance,  tedious,  and 
exceedingly  painful  to  the  patient.  For  complete  fistula  he 
Fig  3.  used  a  probe  with  an  eye  near  its  point, 

which  was  to  be  passed  from  without  to 
within,  carrying  the  india-rubber  and  a 
strong  thread,  so  that  if  the  india-rubber 
•5  broke  in  tying,  another  ligature  could  be 
•|  drawn  by  the  thread  through  the  sinus. 
rt  Another  method  was  to  pass  a  tubular 
■|j  probe  ;  through  the  tube  a  fine  wire  was 
J  to  be  introduced,  and  the  end  hooked 
^  down  by  the  finger  passed  into  the  bowel; 
J  the  probe  was  then  to  be  withdrawn  so 
2  that  the  wire  traversed  the  fistula,  one 
■-3  end  hanging  from  the  outer  opening,  the 
^  other  emerging  from  the  anus  ;  the  India- 
's -rubber  was  then  to  be  fastened  to  the 
,s'i  wire  and  drawn  through  the  fistula.  This 
^  I  was  really  a  very  difficult  task  to  accom- 
•70  plish;  sometimes  the  wire  broke  and  the 
•£J  probe  had  to  be  reintroduced,  it  was 
o-;^  therefore  found  better  to  attach  to  the 
=  c  wire  a  piece  of  strong,  thin  cord,  and 
|J  draw  that  through  the  probe,  and  then 
y>  attach  to  it  the  india-rubber,  which,  in 
i  its  turn,  was  at  last  got  into  the  desired 
^  position.  I  need  scarcely  say  that  this 
^  is  a  very  lengthy,  as  well  as  painful, 
c  mode  of  procedure,  as  the  thin  wire  or 
^  cord  cuts  the  inner  opening  of  the  fistula. 
•|  For  cases  of  incomplete  fistula  Professor 
i  Dittel  recommends  a  director  to  be 
-  passed  as  far  as  possible  up  the  sinus, 
•0  and  along  the  groove  a  sharp  needle 
^  armed  with  the  india-rubber  is  to  be 
carried  and  the  bowel  perforated,  the 
ligature  drawn  from  the  eye  of  the  needle 
by  the  finger,  and  the  needle  removed. 
This,  I  may  remark,  if  the  sinus  runs  far 
up  the  bowel,  is  by  no  means  so  simple  of  accomplishment 
as  it  may  appear.  Being,  then,  very  dissatisfied  with  these 
methods  of  operating,  I  set  myself  to  find  some  better  and 
simpler  plan,  and  on  reflection  I   came   to  the   conclusion 


FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE.     33 

that  the  india-rubber  could  be  drawn  much  more  readily 
from  within  the  rectum,  through  the  internal  opening  (or 
through  an  anificial  i^erforation  in  the  bowel),  than  by  com- 
mencing to  pass  it  from  the  external  opening.  This  con- 
viction led  me  to  devise  this  simple  instrument  (which  is 
shown  in  the  wood-cut)  for  drawing  a  ligature  through  a 
fistulous  sinus  or  beneath  a  tumor,  and  Messrs.  Krohne  and 
Sesemann  have  with  much  care  and  pains  rendered  it,  in  my 
opinion,  practically,  quite  perfect. 

It  consists,  as  will  be  seen,  in  the  combination  of  a  con- 
cealed hook  or  notch,  with  a  blunt  or  sharp-pointed  probe, 
as  the  case  may  require.  A  shows  the  curved  probe  with 
the  hook  concealed  by  the  sliding  canula,  ready  to  be  passed 
through  a  fistula,  or,  if  a  sharp  point  be  substituted  for  a 
blunt  one,  under  a  tumor.  B  exhibits  the  instrument  with 
the  canula  drawn  back,  and  the  previously  concealed  notch 
exposed  ready  to  receive  the  loop  of  India-rubber;  when 
this  is  placed  in  the  notch,  the  canula  is  pushed  home,  and 
the  ligature  is  held  so  firmly  that  it  cannot  escape.  Thus  a 
double  ligature  can  be  readily  drawn  through  a  fistula  or 
beneath  a  tumor.  It  is  not  necessary,  in  fistula,  to  see  the 
hook,  for  if  the  finger,  with  a  loop  of  India-rubber  around 
it,  be  passed  up  the  rectum,  the  loop  can,  with  perfect 
facility,  and  without  the  aid  of  vision,  be  directed  over  the 
end  of  the  probe  and  caught  in  the  notch.  C  shows  the 
sharp-pointed  instrument  adapted  to  the  same  canula,  so 
that  only  one  handle  and  one  canula  are  required  to  com- 
plete the  double  instrument.  It  is  obvious  that  with  my 
instrument  a  double  ligature  is  carried  through  the  sinus; 
this  is  an  advantage,  for  if  the  india-rubber  breaks  as  it  is 
being  tied,  there  is  a  second  ligature  to  fall  back  upon.  I 
ceased,  however,  to  use  the  knot  very  soon  after  making 
trial  of  the  ligature,  and  I  now  use  only  a  small  oval  ring  of 
soft  metal;  the  two  ends  of  the  ligature  are  threaded  through 
this,  the  india-rubber  is  pulled  as  tight  as  is  required,  and 
the  metal  ring  is  then  closed  by  a  strong  pair  of  forceps. 
The  ring  holds  perfectly  tight,  it  never  breaks  the  ligature, 
never  gives  way>  and  the  closure  is  effected  in  a  moment. 


34  OPERATIONS   ON    FISTULA    IN    ANO. 

CHAPTER    V. 

OPERATIONS    ON     FISTULA    IN    ANO. 

Before  proceeding  to  operate  upon  a  case  of  fistula,  it  is 
highly  important  that  the  bowels  should  be  well  cleared  out, 
and  I  preter,  whenever  possible,  to  administer  a  purge  three 
days  prior  to  operating,  and  again  the  night  before;  an 
injection  may  also  be  given  in  the  morning. 

The  patient  should  be  placed  on  a  hard  mattress,  on  the 
side  on  which  the  fistula  exists,  the  buttocks  being  brought 
quite  to  the  edge,  or  rather  overhanging  the  edge  of  the 
couch,  and  the  knees  well  drawn  up  to  the  abdomen.  I  have 
no  hesitation  in  saying  that,  for  the  majority  of  rectal  oper- 
ations, this  position  is  by  far  the  most  convenient,  both 
for  the  surgeon  and  the  patient,  but  occasionally  the  litho- 
tomy posture  is  preferable,  as,  for  example,  in  performing 
excision  of  the  rectum.  Now,  take  a  Brodie's  probe  direc- 
tor, made  of  steel,  with  a  small  probe  point;  oil  it  and  pass 
it  into  the  external  opening,  through  the  sinus  and  the 
internal  opening,  if  possible;  then  insert  your  finger  into  the 
rectum,  and  on  feeling  the  point  of  the  director  in  the 
bowel,  if  the  patient  be  not  anaesthetized,  tell  him  to  strain 
down;  yon  will  then  be  able,  without  any  difficulty,  to  turn 
the  point  out  of  the  anus.  Tins  done,  the  tissues  forming  a 
bridge  over  the  director  are  to  be  divided  with  a  curved 
bistoury. 

If  the  fistula  be  deep,  running  beneath  the  sphincters,  you 
will  not  be  able  to  get  the  point  of  the  probe  out  at  the 
anus,  even  if  the  patient  be  anaesthetized;  in  such  a  case 
you  must  pass  the  director  well  through  the  sinus,  then 
insert  your  left  forefinger  into  the  rectum,  steady  the 
director,  and  run  a  straight  knife  along  the  groove,  catting 
carefully  toward  the  bowel  until  the  parts  are  severed.  This 
is  by  no  means  an  easy  operation,  and  requires  much  prac- 
tice and  experience  to  accomplish  quickly  and  without 
bungling.  To  the  inexpert  surgeon,  in  such  a  case,  I  recom- 
mend my  deeply  grooved  director  and  scissors,  which  I  shall 
describe  furthtr  on  ;  I  may  add  that  gentle  dilatation 
of  the  sphincters,  under  these  difficulties,  gives  the  surgeon 
an  immense  advantage,  of  which  I  now  constantly  avail 
myself. 

If  there  be  no  interrial  opening,  you  will  almost  alw^ays 


OPERATIONS   ON    FISTULA    IN    ANO.  35 

find  some  part  where  only  mucous  membrane  intervenes 
between  the  point  of  the  probe  and  your  finger.  At  this 
spot  work  the  director  through,  and  bring  down  the  point  as 
before.  You  must  not  rashly  thrust  the  point  of  the  probe 
through  the  mucous  membrane,  or  you  will  wound  your  own 
finger;  this  accident  may  always  be  avoided  by  a  little  gentle 
and  patient  manipulation,  even  when  the  tissues  are  indur- 
ated. When  you  have  divided  the  fistula  from  the  external 
to  the  internal  opening,  search  higher  with  the  probe  for  any 
sinus  running  up  beyond  the  internal  opening;  if  this  exists 
you  should  lay  it  open. 

I  know  many  authorities  have  stated  that  it  is  only  neces- 
sary to  incise  the  fistula  between  its  external  and  internal 
openings,  and  that  the  sinus  above  the  internal  opening  will 
spontaneously  close;  my  experience  is  most  decidedly 
opposed  to  this  statement. 

In  the  great  majority  of  cases  you  will  not  cure  your 
patient  unless  you  lay  the  whole  sinus  open,  from  end  to 
end.  Over  and  over  again  I  have  left  the  sinus  above  the 
internal  opening  uninterfered  with,  and  almost  invariably 
have  had  to  regret  having  done  so,  and  to  perform  a  second 
operation.  It  constantly  occurs  to  me,  at  St.  Mark's,  to 
treat  cases  which  have  been  operated  on  at  other  hospitals, 
the  upper  part  of  the  sinus  having  been  left  and  the  patient 
not  being  cured.  In  such  cases  fresh  or  continued  burrowing 
takes  place  from  the  upper  track,  and  a  second  operation, 
often  more  severe  than  the  first,  is  rendered  necessary.  It 
needs  scarcely  be  said  that  in  private  practice  this  is  very 
damagmg  to  the  surgeon's  reputation. 

Having,  then,  opened  the  fistula  in  its  whole  length  upward, 
search  for  lateral  sinuses  extending  from  the  outer  opening; 
also  see  if  there  be  any  burrowing  outward  beyond  the  outer 
opening.  A  fistulous  orifice  is  only  not  at  either  end  of  the 
sinus,  but  somewhere  in  its  course.  Examine  carefully  to 
see  if  there  be  a  secondary  sinus  running  from  and  beneath 
the  track  of  the  main  sinus.  Frequently,  in  fact  nearly 
always,  in  old  standing  cases,  the  deeper  sinus  does  exist, 
and  unless  it  is  incised  with  the  rest  the  patient  will  not  get 
well. 

Here,  again,  some  surgeons  have  asserted  that  it  is  unnec- 
essary to  divide  any  but  the  principal  sinus,  for  that  if  this 
is  done  the  rest  will  heal.  On  this  point  I  cannot  speak 
too  strongly.  I  am  certain  you  can  never  guarantee  the 
healing  of  a  fistula  so  long  as  any  lateral  or  deep  sinuses 


36  OPERATIONS    ON    FISTULA    IN    ANO. 

remain;  and  so  long  as  they  do  remain  fresh  sinuses  are  apt 
to  form.  As  a  rule,  the  best  plan  is  to  lay  open  the  original 
sinus  first  and  the  tributary  ones  afterwards. 

It  is  impossible,  in  any  work,  to  do  more  than  lay  down 
general  rules;  every  case  will  call  more  or  less  upon  the 
surgeon's  knowledge,  dexterity,  and  prudence;  but  in  thus 
strongly  expressing  my  opinion,  contrary  to  the  dicta  of 
many  eminent  men,  I  can  only  say  that  I  am  stating  what 
I  see  almost  every  day  to  be  the  truth. 

When  all  the  sinuses  are  slit  up,  with  a  pair  of  scissors 
take  off  a  portion  of  the  overlapping  edges  of  skin;  they 
are  often  thin  and  livid,  having  very  little  vitality.  If  not 
removed,  they  will  fall  down  into  the  wound  and  materially 
retard  the  healing  process.  I  have  frequently  induced 
healing  in  a  fistulous  track  which  had  been  only  laid  open, 
by  paring  off  the  edges  of  the  skin  which  were  undermined. 
It  must  be  observed  that  I  am  not  advocating  ''the  cutting 
out  of  a  fistula,"  as  it  used  to  be  called;  I  am  only  recom- 
mending the  removal  of  any  overhanging,  undermined, 
degenerate  skin.  When  several  sinuses  have  to  be  laid  open, 
I  am  in  the  habit  of  carefully  preserving  islets  of  skin  from 
the  edges  of  which  granulations  will  take  place,  and  by  which 
cicatrization  is  materially  hastened.  Indeed,  I  have  in  many 
cases  practiced  skin-grafting  with  good  results,  though  fail- 
ures have  not  been  infrequent.  In  old-standing  cases,  where 
there  is  much  induration,  it  is  very  good  practice  to  draw  a 
straight  knife  through  the  dense  track  of  the  fistula,  and  out- 
ward beyond  the  external  opening;  it  is  wonderful  how  rap- 
idly quite  cartilaginous  hardness  passes  away  after  this  has 
been  done.  This  incision  was  commonly  practiced  by  the 
late  Mr.  Salmon.  He  called  it  his  "back cut,"  and  although 
if  carried  to  excess  incontinence  of  faeces  may  result,  I  have 
no  hesitation  in  saying  that  Mr.  Salmon  cured  many  cases 
by  this  means  where  other  surgeons  had  failed. 

Having  completed  your  operation,  take  some  finely  carded 
cotton  wool,  and  with  a  probe  pack  it  well  into  the  bottom 
of  the  wound,  packing  it  into  every  part,  and  being  the  more 
particular  about  this  if  your  incisions  have  been  extensive, 
or  pass  high  up  the  bowel,  or  if  the  parts  are  very  dense 
and  gristly,  as  they  are  in  old  fistulae,  and  especially  in  cases 
operated  upon  for  the  second  time.  A  good,  firm  pad  of 
wool  should  then  be  placed  between  the  buttocks,  over  the 
wounds,  and  a  T-bandage  firmly  applied.  With  these  pre- 
cautions you  need  never  fear  haemorrhage,  for  if  the  bleed- 


OPERATIONS    ON    FISTULA    IN    ANO. 


37 


Fig.  4. 


ing  be  thus  arrested  by  pressure  at  first  all  will  be  well; 
if,  however,  the  wool  be  carelessly  stuffed  into  the  bowel 
without  method,  it  will  not  be  placed  evenly  at  the  bottom 
of  the  wound,  and  then,  as  soon  as  the  patient  rallies  from 
the  shock  of  the  operation  bleeding  will  recommence,  and 
both  patient  and  surgeon  will  be  put  to  much  annoyance, 

and  probably  some  anxiety. 
Of  course,  if  you  see  a  large 
vessel  spurting  at  the  bot- 
tom of  a  wound  it  is  best  to 
close  it  by  torsion  ;  when, 
however,  the  track  of  the 
fistula  is  very  callous  you 
cannot  twist  the  vessel,  and 
a  ligature  may  then  be  ap- 
plied. By  careful  atten- 
tion to  the  details  above 
given,  a  sinus  may  be  open- 
ed to  any  possible  distance 
up  the  bowel,  or  in  any 
direction  or  depth,  without 
positive  danger,  but  on  the 
whole,  for  very  deep,  bad 
fistulae,  the  elastic  ligature 
is,  as  I  have  before  said, 
generally  to  be  preferred. 

If  the  rectal  sinus  runs 
up  so  high  and  the  parts 
are  so  dense  that  you  can- 
not get  the  point  of  your 
probe-director  out  of  the 
anus,  and  you  prefer  to  cut, 
the  safest  and  easiest  way 

It  should  be  observed  that  the  scissors  can   ^f     operating     is     with     the 
only  be  removed  from   the  groove  by  drawing  10  ^         '-'^^^ 

them  out  towards  the  handle  of  the  director. 

At  the  side  is  shown  the  strong  spring  scissors 
sed.  at  St.  Mark's  Hospital  in    the  operation 

upon  internal  hemorrhoids.  and  first  made  by  Ferguson, 

of  Giltspur  street,  London;  with  this  instrument  you  can 
divide  fistulae  high  up  the  bowel,  however  dense  they  may 
be,  with  great  facility  and  quickness.  The  director  is 
made  with  a  deep  groove,  the  section  of  which  is  more  than 
three-quarters  of  a  circle;  in  this  the  globe-shaped  probe- 
point  of  one  blade  of  the  scissors  runs.  Once  placed  in  the 
groove  it  cannot  slip   out;  so,  having  passed  your  director 


Spring  Scissors,  with  Probe  Point  in  the 
Grooved  Director. 


spring-scissors  and  special 


spring  scissors    j*        _4.  j        •  11 

used  at  St.  Mark's  Hospital  in"  the  operation   QireCtOr,     designed     by     me 


38"  OPERATIONS    ON    FISTULA    IN    ANO. 

through  the  sinus,  you  introduce  the  fore-finger  of  your  left 
hand  into  the  bowel,  then  insert  the  probe-pointed  blade  of 
the  scissors  into  the  groove  in  the  director,  and  run  it  along, 
cutting  as  you  go,  the  finger  in  the  bowel  preventing  the 
healthy  structures  from  being  wounded.  By  this  instrument 
operations  usually  very  difficult,  and  in  which,  without  great 
caution,  you  are  apt  to  break  your  knife,  are  rendered  quite 
simple.  A  country  hospital  surgeon  told  me  that  after  see- 
ing my  description  of  this  instrument  he  procured  one,  and 
uses  it  in  all  his  cases  of  fistula;  he  says  it  is  "  operating 
made  easy."  I  have  not  said  a  word  about  the  old  method 
of  operating,  usually  described  in  works  on  surgery,  because 
I  consider  the  mode  I  have  detailed  so  much  more  satisfac- 
tory and  practicable. 

It  was  in  cases  of  sinuses  running  high  up  in  the  rectum, 
or  where  stricture  existed  in  conjunction  with  fistula  (the 
internal  aperture  being  above  the  stricture)  that  Mr.  Luke, 
in  the  year  1845,  recommended  cutting  through  the  diseased 
structures  by  means  of  a  fine  piece  of  strong  twine  and  a 
screw-tourniquet.  It  is  an  operation  by  no  means  easy  of 
performance,  but  this  is  the  way  in  which  it  is  done,  and 
it  was,  no  doubt,  very  useful  in  some  cases.  Introduce  a 
hollow  probe  through  the  sinus  and  into  the  bowel,  then  pass 
a  piece  of  thin  wire  through  it,  hook  the  end  down,  and 
bring  it  out  at  the  anus;  then  withdraw  your  probe,  fasten 
the  twine  to  one  end  of  the  wire,  and  draw  on  the  other  end 
By  this  means  you  get  the  twine  to  traverse  the  smus,  one 
end  coming  out  at  the  anus  and  the  other  at  the  external 
opening  of  the  fistula.  Attach  the  twine  now  to  your 
tourniquet,  and  screw  up  a  little  every  day  or  two.  In  this 
way  you  may  cut  through  very  dense  structures  without  any 
great  danger;  but  the  method  is  often  painful,  and  is  apt  to 
cause  inflammation,  suppuration,  and  fresh  abscesses.  I 
have  noticed  these  results  in  my  own  practice,  and  also  in 
that  of  my  colleagues.  But  in  all  these  cases  the  elastic 
ligature  is  so  very  superior,  being  more  easily  applied, 
quicker  in  action,  and  absolutely  painless,  that  I  cannot 
conceive  of  anyone  using  Mr.  Luke's  tourniquet  now. 

When  the  fistula  is  complete,  wind  may  pass  through  it, 
and  also  faeces,  if  the  bowels  are  relaxed;  as  a  rule,  however, 
this  symptom  does  not  occur,  in  consequence  of  the  small- 
ness  of  the  internal  aperture,  its  situation,  or  its  valvular 
form.  It  follows  ihat,  though  the  passage  of  wind  is  a  cer- 
tain indication  of  a  complete  fistula,   the  absence  of  this 


OPERATIONS   ON    FISTULA    IN    ANO.  39 

symptom  should  not  induce  the  belief  that  there  is  no  inter- 
nal opening. 

The  most  painful  form  of  fistula,  at  the  same  time,  for- 
tunately, the  most  uncommon,  is  the  blind  internal  fistula. 
I  have  seen  many  cases  where  the  aperture  was  as  large  in 
circumference  as  a  threepenny-piece;  the  faeces,  when  liquid, 
pass  into  the  sinus  and  create  great  suffering — a  burning 
pain  often  lasting  all  day  after  the  bowels  have  acted. 
Moreover,  these  fistulse  are  frequently  severe,  m  consequence 
of  the  burrowing  caused  by  the  irritating  matters  which  get 
into  them. 

In  operating  upon  a  blind  internal  fistula,  if  you  can  feel, 
by  the  hardness  externally,  the  site  of  the  abscess,  you  may 
plunge  your  knife  into  it,  and  thus  make  a  complete  fistula, 
through  which,  of  course,  you  pass  your  director.  If  you 
cannot  feel  any  hardness  or  see  any  discoloration  to  guide 
you  to  the  situation  of  the  sac  of  the  abscess,  the  best  w^ay  of 
proceeding  is  to  bend  a  silver  probe-director  into  the  form 
of  a  hook,  and  then  hook  this  into  the  internal  aperture, 
and  bring  the  |)oint  down  close  under  the  skin;  you  then  cut 
upon  it,  thrust  it  through,  and  complete  the  operation. 

This  re(|uires  a  little  dexterity  and  some  practice  to  man- 
age well,  but  it  is  by  far  the  surest  way  of  hitting  off  the 
sinus.  These  cases  of  blind  internal  fistula  are  very  often 
not  understood,  and  consequently  are  mistaken  for  other 
diseases.  Not  infrequently  an  internal  fi.->tiila  is  connected 
with  haemorrhoids.  I  have  seen  many  such  cases.  I  think 
when  strong  applications  are  made  to  haemorrhoids,  suppura- 
tion may  be  set  up,  and  then  an  internal  fistula  may  form. 
Here  is  a  case,  probably,  of  that  kind  : — 

A  gentleman  came  to  me  this  year  having  great  pain  in 
the  rectum  on  and  after  defecation,  generally  worse  after; 
sometimes  coming  on  half  an  hour  after  leaving  the  closet. 
His  history  was  that  he  had  suffered  from  haemorrhoids,  which 
came  down  and  bled,  and  that  about  seven  weeks  before 
seeing  me  he  had  undergone  an  operation  for  the  cure  of  the 
piles.  The  operation  consisted  in  thrusting  a  cautery  iron 
into  all  the  piles;  great  pain  followed,  and  he  kept  his  couch 
for  fourteen  days,  when  he  began  to  feel  better,  and  his  piles 
did  not  come  down,  but  there  was  discharge  of  matter.  He 
was  told  that  now  all  was  right,  and  in  a  few  days  he  might 
go  about  as  usual,  but  after  another  week  he  still  had  pain 
on  and  after  stool,  and  lost  blood.  He  went  into  the  coun- 
try, but,  not  getting  well,  at  last   sought  my  advice.     On 


40  OPERATIONS    ON    FISTULA    IN    ANO. 

passing  my  finger  into  the  rectum,  T  found  a  large,  deep 
ulcer,  and  a  sinus  running  from  it  upward  and  downward; 
the  piles  which  still  existed  were  angry  and  tender,  and  very 
ready  to  bleed.  As  nothing  but  an  operation  could  cure 
him,  I  slit  up  the  sinuses,  drew  a  straight  knife  through  the 
bottom  of  the  ulcer,  bringing  it  right  out  so  as  to  divide  the 
sphincter  freely.  I  also  placed  two  fine  ligatures  around  the 
haemorrhoids.  He  had  no  bad  symptom,  remarkably  little 
pain,  and  was  quite  well  in  five  weeks.  In  this  case,  the 
thrusting  of  a  fine  cautery  set  up  suppuration,  and  caused 
an  abscess,  which,  bursting,  made  a  great  ulcer,  and  which 
ulcer  formed  the  internal  opening  to  the  sinuses. 

These  cases  of  blind  mternal  fistula  are  instructive;  I  will 
therefore  relate  another: — 

I  saw,  with  my  late  friend,  Mr.  T.  Carr  Jackson,  a  profes- 
sional brother  who  had  been  suffering  for  some  time  from 
pain  on  defecation,  and  burning  afterwards,  with  discharge 
of  matter  always  upon  the  motions;  he  was  also  much  trou- 
bled with  his  water,  having  considerable  irritation  of  the 
bladder.  He  had  been  operated  upon,  but  without  getting 
any  better;  there  was  no  ulceration,  nor  was  there  any 
fissure.  On  examining  this  gentleman  I  at  once  found  what 
I  expected,  a  small  internal  aperture  about  two  inches  from 
the  anus;  from  this  a  sinus  ran  upward  and  downward.  The 
anus  (with  its  outside  surroundings)  was  perfectly  healthy. 
Mr.  Jackson,  assisted  by  me,  at  once  slit  up  the  sinuses,  and 
the  patient  was  rapidly  and  permanently  cured;  all  his  blad- 
der symptoms  likewise  vanished. 

These  cases  of  internal  fistula  require  very  careful  exam- 
ination to  make  a  correct  diagnosis.  Often  the  surgeon 
finds  an  ulcer,  but  does  not  attempt  to  pass  a  probe  into  it. 
Truly  it  is  an  ulcer,  but  in  addition  it  is  the  opening  of  an 
internal  fistula,  which  may  burrow  in  more  than  one  direc- 
tion. Operations  upon  internal  fistula  also  require  more 
than  ordinary  care.  If  you  find  an  internal  opening  in  the 
bowel,  and  a  sinus  running  up  higher  from  it,  never  lay  the 
sinus  open  simply;  in  the  first  place,  if  you  do,  you  are  very 
likely,  after  you  leave  yoar  patient,  as  you  think,  quite  safe, 
to  have  some  haemorrhage  take  place,  and  the  blood  will  be 
retained  in  the  rectum  until  so  much  has  accumulated  that 
the  patient  must  pass  it.  In  such  a  case  always  bring  your 
incision  out  through  the  anus,  that  no  blood  may  be  retained. 
Blood  retained  iii  the  hot  rectum  foments  the  part,  and  pre- 
vents coagulation  and  closing  of  the  vessels,  which  are  fre- 


OPERATIONS   ON    FISTULA    IN    ANO.  4I 

quently  large  and  increased  in  calibre  by  the  long-continued 
inflammation  of  the  part.  Again,  if  you  divide  an  internal 
sinus,  you  make  a  deep  cavity  whence  pus  or  discharge  can- 
not thoroughly  escape,  and  in  consequence  the  wound  will 
not  heal. 

Whenever  you  have  to  make  an  incision  through  the 
mucous  membrane  and  into  the  submucous  tissue  in  the 
rectum,  without  continuing  your  cut  to  the  outer  parts, 
beware  of  haemorrhage.  Plug  the  rectum  well  and  use  a 
styptic,  either  the  subsulphate  of  iron  or  a  saturated  solution 
of  tannin. 

I  have  seen  one  death  from  this  form  of  haemorrhage  occur 
in  the  hands  of  a  very  good  surgeon,  and  another  case 
recently,  during  very  hot  weather,  in  which  a  patient  most 
narrowly  escaped  with  his  life,  from  a  like  want  of  care. 

Internal  fistula,  as  I  have  already  said,  may  commence  by 
an  ulceration  of  the  mucous  membrane;  or  perhaps  more 
rarely,  by  a  small  abscess  forming  in  the  submucous  areolar 
tissue;  this  may  be  the  result  of  wounding  or  bruising  by 
hardened  faeces  or  foreign  bodies  swallowed.  Of  this  I  will 
mention  two  excellent  examples  I  have  seen,  one  in  the 
practice  of  Dr.  Cottew,  of  Hornsey,  and  the  other  in  that  of 
Mr.  Kelson  Wright,  Of  Brixton.  Here  two  ladies  com- 
plained of  considerable  pain  in  the  rectum.  On  examina- 
tion in  each  case  a  rounded,  hard  swelling  was  felt,  about  an 
inch  from  the  verge  of  the  anus.  On  more  carefully  invest- 
igating, a  very  small  orifice  was  found  running  into  this 
swelling.  In  both  instances  foreign  bodies,  i.  e.,  fish  bones, 
had  been  felt  by  the  medical  attendants  before  I  saw  the 
patients. 

I  am  decidedly  of  opinion  that  when  internal  fistula  com- 
mences by  ulceration  it  is  most  frequently  found  associated 
with  phthisis.  I  shall  not  go  into  this  important  question 
here,  intending  to  devote  the  next  chapter  to  the  special 
consideration  of  this  subject. 

In  operating  upon  women  suffering  from  fistulae  (espe- 
cially when  the  sinus  is  near  the  perineum),  cut  as  little  as 
possible,  for  anything  like  too  free  incisions  are  apt  to  end  in 
incontinence  of  faeces,  or,  at  all  events,  in  such  partial  loss  of 
power  in  the  sphincter,  as  to  prevent  the  patient  retaining 
flatus,  a  result  which,  I  need  scarcely  say,  is  a  most  disagree- 
able one.  I  have  been  several  times  consulted  by  ladies  on 
account  of  this  condition,  and  in  some  cases  1  have  been  suc- 
cessful in  restoring  the  lost  power,  much  to  my  patient's  sat- 


42  OPERATIONS   ON    FISTULA   IN   ANO. 

isfaction.  Of  very  great  importance  is  the  question  of 
incontinence  of  faeces,  w.liich  may  result  from  extensive  ope- 
rations on  the  rectum,  where  the  sphincter  muscles  are  freely 
divided.  A  patient  who  suffers  from  inability  to  retain  flatus 
or  faeces  is  in  a  most  unpleasant  condition;  in  fact,  some 
sensitive  persons  would  not  undergo  any  operation  which 
was  at  all  likely  to  induce  such  a  state,  and  would  prefer  any 
physical  suffering  rather  than  the  perpetual  fear  of  being  in 
any  way  offensive  to  others.  It  behooves  us,  then,  to  con- 
sider how  much  we  dare  do  without  danger  of  damaging  or 
destroying  the  power  of  the  muscles  at  the  outer  end  of  the 
rectum.  Should  you  feel  doubtful  about  the  preservation  of 
this  power,  you  are  bound  to  tell  your  patient  what  may  hap- 
pen, and  then  place  the  good  and  evil  before  him;  if  you  fail 
to  do  this,  and  the  patient  recovers,  with  much  loss  of  the 
power  of  retention,  he  is  justified  in  complaining  of  your 
treatment.  Incontinence  of  wind  or  liquid  faeces  results 
almost  always  from  cutting  the  muscles,  and  principally  the 
internal  sphincter  in  more  than  one  place.  If  you  have  a 
double  fistula,  /.  <?,,  one  on  each  side  of  the  bowel,  running 
deeply  beneath  the  internal  sphincter,  and  you  divide  both 
muscles,  great  loss  of  power  you  most  assuredly  will  have. 
If  you  can  leave  ever  so  narrow  a  ring  of  the  upper  part  of 
the  band  of  internal  sphincter,  you  are  fairly  safe.  On  one 
side  you  may  divide  the  sphincters  quite  through  without 
danger  if  you  will  only  take  care  that  your  incision  is  made 
quite  at  right  angles  to  the  fibres  of  the  muscles.  If  you 
divide  the  muscles  at  all  obliquely,  you  never  obtain  good 
union,  and  even  in  comparatively  slight  cases  you  may  get 
incontinence;  I  am  quite  sure  this  is  the  secret  of  operating 
in  bad  cases  without  destroying  the  power  of  the  muscles. 

The  method  I  have  adopted  in  cases  of  incontinence  of 
flatus  and  liquid  faeces,  is  the  use  of  the  actual  cautery.  I 
prefer  the  thermo-cautery  of  Paquelin.  By  its  judicious 
application  you  can  stimulate  the  muscular  fibres,  and  cause 
them  to  contract,  and  by  diminishing  the  circumference  of 
the  anus  obtain  action  of  the  fibres  which  are  left.  I  have, 
now,  in  a  great  many  cases  effected  such  improvement,  if 
not  cure,  as  to  earn  the  gratitude  of  my  patients.  Some 
time  back  I  operated  on  a  lady  from  Doncaster.  It  was  as 
bad  a  fistula  as  one  could  well  see.  Here,  after  dividing 
several  superficial  sinuses  outside  the  anus,  I  found  one  deep 
sinus  running  under  both  sphincters  and  up  the  bowel  be- 
yond the  upper  edge  of  the  internal  muscle.     I  divided  the 


OPERATIONS    ON    FISTULA    IN    ANO.  43. 

sinus  with  the  elastic  ligature  (taking  care  to  cut  at  right 
angles  to  the  muscle),  the  recovery  was  perfect,  and  not  the 
slightest  loss  of  control  resulted. 

After  an  operation  for  fistula  the  bowels  should  be  kept 
confined  for  about  three  days,  a  mild  purge  may  then  be 
administered,  and  full  diet  allowed.  The  wool  usually 
comes  out  when  the  bowels  act,  but  if  it  does  not  come 
away,  I  gently  and  gradually  remove  it. 

If  much  wool  has  been  put  into  the  rectum,  to  prevent 
haemorrhage,  I  generally  take  away  a  portion  of  it  the  next 
day,  leaving  some  only  at  the  bottom  of  the  wound.  If  the 
whole  plug  is  left  in  the  patient  will  probably  be  very  uncom- 
fortable, as  he  cannot  easily  get  rid  of  wind,  and  the  danger 
of  primary  haemorrhage  being  over  in  twenty-four  hours, 
there  is  nothing  gained  by  retaining  a  mass  of  wool  in  the 
bowel. 

Very  little  dressing  is  required  in  the  after  treatment  of 
fistula;  in  fact,  it  is  better  to  do  too  little  than  too  much. 
If  lint,  wool,  or  any  other  foreign  body  is  daily  thrust  into 
the  wound,  it  is  not  at  all  likely  to  heal  kindly;  a  little  cotton 
wadding,  or  fine  oakum,  laid  quite  gently  in  the  wound,  to 
absorb  the  discharge  and  keep  the  edges  from  uniting,  is  all 
that  is  wanted.  I  have  constantly  seen  the  healing  process 
delayed  by  too  great  interference,  e.  g.,  probing,  and  putting 
lint  and  ointments,  or  lotions,  into  the  sore,  I  very  rarely 
use  anything  but  the  dry  wool,  and  I  am  no  advocate  for 
dressings  of  any  kind;  only  when  the  wound  is  unhealthy  or 
sluggish  do  I  prescribe  lotions;  then,  according  to  circum- 
stances, black  wash,  carbolic  acid,  nitric  acid,  the  subsul- 
phate  or  tartrate  of  iron  lotions,  may  be  advantageous.  The 
compound  tincture  of  benzoin  I  have  found  to  be  an  excel- 
lent application.  For  the  first  few  days  I  have  sometimes 
employed  carbolized  oil,  i  to  19,  as  it  keeps  the  wound 
moist,  but  you  must  not  go  on  long,  or  the  granulations  will 
be  destroyed  by  the  acid,  and  the  edges  of  the  wound  becom- 
ing quickly  irritated,  cicatrization  will  be  thus  retarded. 
When  any  irritation  is  seen  around  the  wound,  there  are  few 
better  dressings  than  fresh,  pure  olive  oil;  it  sheathes  the 
part,  is  very  soothing  and  grateful  to  the  patient,  and  under 
its  use  granulation  goes  on  rapidly,  the  wound  is  probably 
nourished  by  the  oil,  and  there  is  a  remarkably  small  quan- 
tity of  pus  discharged. 

Although  the  surgeon  should  not  interfere  with  nature's 
work,  he  must  be  always  on  the  watch,  during  the  healing 


44  OPERATIONS    ON    FISTULA    IN    AND. 

process,  for  any  burrowing  or  formation  of  fresh  sinuses; 
and  I  wish  to  state  that  such  development  is  generally  indi- 
cated by  the  sudden  (and  otherwise  unaccountable)  augmen- 
tation of  the  purulent  discharge.  Whenever  a  wound  secretes 
more  than  its  surface  seems,  from  your  experience,  to  war- 
rant, be  sure  that  burrowing* has  commenced,  and  search 
diligently  for  the  sinus  at  once,  for  the  longer  it  is  left  the 
larger  and  deeper  it  will  get.  Sometimes  it  is  under  the 
edges  of  the  wound  that  it  commences;  at  others,  at  the  end 
of  the  wound,  internally  or  externally,  and  occasionally  it 
seems  to  dive  down  from  the  base  of  the  main  fistula.  When 
the  sinus  is  found,  I  need  scarcely  say  that,  as  a  rule,  it 
should  be  laid  open  at  once.  One  other  point :  always 
encourage  your  patient  to  tell  you  directly  he  has  any  pain 
in  or  near  the  healing  fistula  ;  never  make  light  of  his  com- 
plaints; often  he  will  be  the  first  to  discover,  by  the  exist- 
ence of  some  unpleasant  sensation,  the  commencement  of  a 
small  abscess  or  sinus,  and  will  be  able  also  to  indicate  its 
situation.  While  I  am  writing  this,  I  have  under  my  care  a 
gentleman  upon  whom  I  operated  three  weeks  ago,  for 
severe  fistula  on  the  left  side,  and  which  has  nearly  healed; 
four  days  back  he  told  me  had  slight  pain  on  the  right  but- 
tock, three  inches  from  the  anus.  I  examined,  but  could 
feel  nothing,  and  my  patient  told  me  all  his  abscesses  on  the 
left  side  commenced  with  the  same  sort  of  pain,  and  he  felt 
sure  another  abscess  was  forming;  and  the  very  next  day  I 
detected  deep-seated  fluctuation.  I  immediately  cut  down 
and  let  out  as  much  pus  as  would  fill  an  egg  cup;  had  this 
been  neglected  the  result  would  have  been  serious. 

No  fixed  rules  can  be  laid  down  for  the  treatment  of  these 
wounds;  it  is  in  getting  them  to  heal  quickly  that  the  skilful 
surgeon  is  shown.  When  to  administer  stimulants,  when 
tonics,  to  feed  the  patient  well,  yet  not  to  over-feed  him,  are 
all  points  in  which  common  sense,  practical  knowledge,  and 
the  observance  of  apparently  small  matters  will  best  guide 
us.  There  are  few  surgical  cases  that  call  more  for  intelli- 
gence and  watchfulness  on  the  part  of  the  surgeon  than  the 
after-treatment  of  a  bad  fistula.  I  have  often  seen  patients 
whom  the  best  and  most  eminent  surgeons  in  London  have 
utterly  failed  to  cure,  because  they  left  the  patient  after  the 
operation  almost  entirely  in  the  hands  of  persons  who  had 
not  much  experience,  and  who  did  not  know  what  to  expect 
and  guard  against.  During  the  healing  process  do  not  purge 
your  patient  much,  but  take  care  that  the  bowels  are  fairly 


OPERATIONS   ON    FISTULA    IN    ANO.  45 

•  relieved;  this  I  generally  accomplish  by  a  mild  alterative 
pill  and  some  Friedrichshall  water  or  other  gentle  laxative. 

It  is  important  that  the  recumbent  position  should  be 
kept  for  some  time  ;  its  duration  must  depend  upon  the 
state  of  health  and  the  extent  and  depth  of  the  wounds  ;  too 
early  or  too  much  standing  or  walking  about  will  not  only 
delay,  but  sometimes  entirely  prevent  cicatrization.  The 
more  I  see,  the  more  confirmed  I  am  in  this  opinion.  The 
sooner  you  can  get  the  wound  to  heal  the  better,  for  it  stands 
to  reason  the  longer  the  w^ound  remains  unhealed  the  greater 
is  the  chance  that  some  fresh  abscess  or  sinus  may  form. 
You  never  ought  to  consider  your  patients  quite  safe  until 
all  sinuses  or  wounds  are  healed  ;  and  if  they  go  from  under 
my  care  before  that,  I  always  tell  them  they  must  take  the 
responsibility  upon  themselves.  I  do  not  keep  my  patients 
long  in  bed,  but  I  make  them  recline  upon  the  sofa  ;  this 
rule  is  especially  advisable  in  delicate  constitutions. 

Never,  if  you  can  avoid  it,  operate  upon  a  fistula  that  is, 
from  any  cause,  acutely  inflamed. 

While  inflammation  is  going  on,  fresh  sinuses  are  likely  to 
form,  the  areolar  tissue  breaking  down  so  readily  ;  if  you 
operate  under  these  conditions,  failure  is  almost  certain  to 
ensue.  All  you  ought  to  do  in  such  a  case  is  to  make  a  free, 
dependent  opening,  and  keep  the  patient  at  rest  until  the 
inflammation  subsides,  the  sac  of  the  abscess  contracts,  and 
the  formation  of  sinuses  is  for  a  time  completed  ;  then,  and 
only  then,  your  operation  stands  a  fair  chance  of  succeeding. 
In  old-standing  cases  of  ulceration  and  stricture  of  the 
rectum,  fistulae  almost  invariably  form,  but  the  internal 
opening  is  very  rarely  above  the  stricture,  where  one  would 
think  it  ought  to  be  ;  sometimes  it  opens  into  the  stricture 
itself,  but  nearly  always  nearer  the  anus  than  the  stricture. 
The  treatment  of  these  cases  wll  be  considered  in  the  chap- 
ters on  Stricture  and  Ulceration. 

It  is  a  rule  with  me  never  to  despise  a  small  fistula,  more 
especially  if  it  be  directly  dorsal  or  perineal ;  often  when 
you  divide  a  seemingly  most  trivial  sinus,  you  find  from  the 
opened  track  a  deeper  one  passing  up  the  bowel,  and  this 
condition,  as  I  have  pointed  out,  is  an  obstacle  to  the  success 
of  the  elastic  ligature. 

Moreover,  when  this  is  not  the  case,  slight  fistulae  are  not 
rarely  difficult  to  heal.  I  have  been  many  times  much 
troubled  by  them,  and  generally  in  cases  where  they  ran 
through  the  fibres  of  the  external  sphincter,  and  not  quite 


46  OPERATIONS   ON    FISTULA    IN    ANO. 

beneath  them,  so  that  in  operating  only  a  portion  of 
that  muscle  was  divided.  The  late  Mr.  Salmon  was  in  the 
habit  of  saying,  when  he  had  laid  open  one  of  these  fistulae  : 
"  Now  I  have  made  a  fissure,  and  I  shall  proceed  to  cure  it," 
and  he  then  drew  his  knife  along  the  base  of  the  sinus  so  as 
to  entirely  divide  the  external  sphincter,  Mr.  Salmon  was  a 
man  of  very  acute  observation,  and  I  am  sure  in  many  such 
instances  this  practice  is  the  best  that  can  be  adopted.  I  do 
not  say  it  is  always  necessary  to  make  a  deep  incision  through 
the  sphincter,  but  I  always  make  one  through  the  muscle  in 
superficial  dorsal  fistulse,  and  I  am  confident  if  you  neglect 
this  precaution  you  will  often  have  difficulty  in  healing  these 
apparently  very  trivial  sores.  If  they  do  not  cicatrize  quickly 
they  become  very  much  like  fissures  in  appearance,  and  the 
patient  will  suffer  pain  more  or  less  severe  after,  as  well  as 
at  the  time  of,  defecation.     Here  is  an  illustrative  case  : — 

A  gentleman  had  been  operated  upon  by  one  of  my  col- 
leagues, for  fistula,  and  got  well,  but  after  some  months 
another  abscess  formed  in  the  site  of  the  old  wound  ;  this 
burst.  When  I  saw  him  there  was  a  very  small  fistula  nearly 
dorsal,  not  deep,  but  tunneling  under  the  old  scar;  I  opened 
this — in  a  fortnight  it  had  not  healed — no  burrowing  had 
taken  place.  I  touched  the  sore  with  nitrate  of  silver,  and 
ordered  him  some  nitrate  of  mercury  and  opium  ointment, 
but  still  it  did  not  heal,  and  in  another  fortnight  he  began 
to  complain  of  pain,  lasting  an  hour,  more  or  less,  after  the 
bowels  acted.  I  now  saw  that  without  a  freer  use  of  the 
knife  it  would  not  heal  at  all,  and  might,  and  probably  would, 
get  deeper;  so  I  persuaded  him  to  lay  up  for  a  few  days,  and  I 
drew  a  fissure  knife  along  the  wound,  beginning  above  it,  and 
coming  below  the  external  end  of  it,  and  I  took  care  to  go 
right  through  the  sphincter.  This  proceeding  settled  the  mat- 
ter; in  about  a  fortnight  he  was  quite  well,  and  he  has  remained 
so.  This  case  made  a  deep  impression  upon  me,  as  I  saw 
that  the  slight  incision  throngh  the  base  of  a  fistula  in  this 
class  of  cases  is  of  no  moment  when  you  are  operating,  and 
it  may  save  you  some  anxiety,  and  perhaps  discredit  also, 
afterwards. 

Here  is  another  case  : — 

A  gentleman  with  an  apparently  very  small  fistula,  situated 
anteriorly,  went  to  an  eminent  surgeon;  It  was  so  slight  that 
the  surgeon  recommended  him  to  be  operated  upon  at  once 
in  his  consulting  room  ;  this  was  done  and  the  patient  went 
home.     After  five  weeks,  the  wound  not  having  healed,  I 


FISTULA   IN   CONJUNCTION    WITH   PHTHISIS.  47 

was  requested  to  see  the  patient,  and  I  found  that  from  the 
bottom  of  the  small  wound  there  ran  a  deep  sinus  up  the 
bowel  and  also  forward  nearly  to  the  scrotum.  I  did  not 
say  that  these  sinuses  might  not  have  foamed  since  the  first 
operation,  bat  the  case  clearly  shows  how  careful  one  ought 
to  be,  both  in  diagnosis  and  prognosis.  A  certain  cure  had 
been  promised,  in  this  case,  in  a  few  days. 


CHAPTER  VI. 

FISTULA   IN    CONJUNCTION    WITH    PHTHISIS. 

From  a  surgical  point  of  view  I  wish  to  consider  phthisis 
as  a  complication  of  fistula.  It  would  doubtless  be  more 
correct  to  regard  fistula  as  one  of  the  complications  of  phthi- 
sis, but  I  think  it  better,  for  my  purpose,  to  put  it  in  the  way 
I  have. 

This  subject  is  one  of  considerable  importance,  and  has 
scarcely,  I  think,  received  from  any  author  the  attention  it 
deserves.  The  majority  of  writers  upon  fistula  have  simply 
expressed  the  opinion  that  in  phthisical  patients  no  interfer- 
ence should  be  attempted  with  the  fistula,  generally  content- 
ing themselves  by  stating  that  if  any  operation  be  performed 
the  wounds  will  not  heal  and  the  patient's  life  will  be  short- 
ened. It  is  the  opinion  of  some  eminent  men  that  fistula 
has  really  the  power  of  arresting,  or  at  all  events  retarding 
the  chest  affection,  and  on  that  ground  they  would  depre- 
cate any  operation.  This  opens  up  a  very  interesting  ques- 
tion, which  I  shall  endeavor  presently,  in  some  degree,  to 
pursue. 

There  are  other  authorities  of  great  experience  in  con- 
sumption who  have  expressed  the  belief  that  the  co-exist- 
ence of  fistula  and  phthisis  is  by  no  means  a  common  one. 
Andral  and  Louis  both  state  that  they  had  very  rarely 
observed  a  conjunction  of  the  diseases.  Andral,  in  fact, 
says  that  out  of  800  patients  affected  with  phthisis  he  noticed 
only  one  case  of  fistula.  According  to  Louis  tubercular 
ulceration  is  very  common  in  the  small  intestine,  and  but 
very  rarely  found  in  the  colon  and  rectum.  The  same 
doubt  as  to  the  prevalence  of  fistula  in  phthisis  has  been 


48  FISTULA    IN    CONJUNCTION    WITH    PHTHISIS. 

expressed  to  me  by  eminent  physicians  whose  opportunities 
of  seeing  pulmonary  affections  have  been  most  extensive. 
Upon  this  point  I  beg  to  make  an  observation  :  I  have  not 
the  shghtest  doubfc  that  there  are  immense  numbers  of  phthi- 
sical persons  in  whom  no  fistulae  exist,  but  I  have  also  no 
doubt  that  there  is  a  very  large  number  of  cases  of  fistulae 
in  which  there  is  tubercular  disease  of  the  lungs. 

A  patient  with  disease  of  the  lungs  going  to  any  of  the 
hospitals  for  phthisis  does  not  say  anything  about  his  fistula 
to  the  attending  physician — he  speaks  only  of  his  chest  ;  but 
the  same  man  comes  to  me,  at  St.  INIark's,  saying  that  he  has 
a  fistula  ;  I  perceive,  perhaps  at  once,  that  he  is  consump- 
tive. Of  course,  the  physician  cannot  see  that  the  phthisi- 
cal patient  has  a  fistula,  and  the  question  is  very  rarely  put; 
of  this  I  am  certain,  as  patients  say,  ''  I  am  attending  at  such 
a  hospital  for  my  cough."  When  I  asked,  did  you  tell  the 
gentleman  you  saw,  that  you  had  fistula  ?  their  reply  almost 
universally  is,  "  No,  sir,  I  did  not." 

For  my  own  part,  I  am  quite  convinced  that  a  very  con- 
siderable percentage  of  fistulous  patients  have  more  or  less 
of  tubercular  lung  affection.  I  have  endeavored  to  find  out 
what  the  percentage  is,  and  I  have  carefully  gone  over  a 
period  of  seven  years  in  private  practice,  from  187 1  to  1877 
inclusive,  and  I  find  that  out  of  792  cases  of  fistula  seen  by 
me  during  that  period,  124  had  phthisis,  either  active  or  lat- 
ent, or  such  symptoms  as  foreshadowed  the  appearance  of 
phthisis,  such,  for  example,  as  narrow  and  flat  chests,  winter 
cough,  continuing  long  through  the  spring,  proneness  to  take 
cold,  feeble  circulation,  and  incapability  for  sustained  phys- 
ical exertion  ;  also  that  facial  expression  which  is  not 
uncommon  ;  and  I  will  add  that  a  bad  family  history  was 
frequently  co-existent.  In  the  years  1878,  '79,  and  '80,  I 
saw,  in  private  practice,  840  cases  of  fistula,  and  of  these 
no  had  symptoms  of  phthisis. 

I  will  here  quote  the  opinions  of  those  entitled  to  respect 
on  the  question  of  operation  on  phthisical  patients. 

Dr.  Bushe,  of  America,  in  his  really  admirable  treatise, 
observes,  "  It  is  very  apparent  that  a  great  many  fistulae 
depend  upon  disease  of  the  lungs,  therefore  we  should  not 
operate  upon  them,  else  the  healing  will  give  rise  to  an 
increase  of  the  pulmonary  disorder  and  curtail  life." 

Mr.  Quain  says,  "  When  the  symptoms  of  tubercular  dis- 
ease of  the  lungs  are  present  the  operation  for  fistula  is  not 
allowable." 


FISTULA   IN    CONJUNCTION    WITH    PHTHISIS.  49 

Mr.  Curling  does  not  express  any  opinion  upon  the  ques- 
tion of  operation,  although  he  notices  the  frequent  concur- 
rence of  the  two  maladies. 

Mr.  Erichsen,  in  his  "  System  of  Surgery,"  objects  to  the 
operation  save  in  a  few  picked  cases. 

In  "  Holmes'  System  of  Surgery"  the  subject  is  dismissed 
with  this  observation  :  ''  If  a  fistula  be  cut  when  a  patient  is 
suffering  from  phthisis,  the  wound,  in  the  majority  of  cases, 
will  not  heal."  This,  I  am  bound  to  say,  is  not  my  experi- 
ence. 

Miller  says,  "  In  phthisical  cases  the  wound,  in  all  proba- 
bility, would  not  heal,  and  supposing  that  it  did  heal,  the 
result  would  probably  be  most  injurious  on  the  system,  the 
pulmonary  disease  advancing  with  fresh  virulence  on  the 
closing  up  of  an  outlet  whence  purulent  and  other  products 
had  been  long  habitually  discharged." 

Dr.  Theophilus  Thomson  states  that  the  co-existence  of 
fistula  with  phthisis  appears  to  retard  the  progress  of  the 
latter  disease,  acting  as  a  derivative. 

In  the  recent  works  on  phthisis  to  which  I  have  had  access 
there  is  no  reference  made  to  the  subject  I  am  treating. 

Dr.  Bristowe,  while  mentioning  the  frequency  of  tubercu- 
lar ulceration  of  the  large  and  small  intestines,  does  not 
allude  to  fistula  in  conjunction  with  phthisis. 

When  we  find  an  opinion  so  decidedly  and  generally 
expressed  by  men  of  acknowledged  ability  and  experience 
of  the  subject  on  which  they  treat,  we  very  naturally  and 
properly  hesitate  to  call  in  question  their  judgment ;  but,  on 
the  other  hand,  we  should  never  be  prevented  from  inquir- 
ing carefully  and  diligently  as  to  the  grounds  upon  which 
that  conclusion  has  been  based  ;  and  should  opportunities 
present  themselves,  we  should  test  whether  the  opinion  is 
founded  on  fact.  I  have  always  thought  that  a  universally 
widespread  belief,  though  perhaps  exaggerated  or  distorted, 
has  some  considerable  element  of  truth  which  had  served  for 
its  origination,  but,  at  the  same  time,  there  is  nothing  more 
likely  to  lead  to  error  and  stifle  the  spirit  of  inquiry  than  a 
too  easy  acquiescence  in  what  may  be  called  "  popular 
creeds." 

It  must  be  obvious  to  everybody  that  to  operate  upon  a 
patient  with  confirmed  and  advanced  tuberculosis  would  be 
a  positive  cruelty,  and  would  undoubtedly  hasten  his  inevit- 
able fate  ;  but  there  are  different  forms  of  phthisis,  some 
evidently  not  so  destructive  as  was  formerly  imagined  ;  and 
4 


5©  FISTULA   IN   CONJUNCTION    WITH    PHTHISIS. 

we  know  that  many  persons  whose  chests  at  one  period  of 
their  lives  exhibited  undoubted  signs  of  breaking  down  of 
pulmonary  tissue,  the  formation  of  cavities,  etc.,  ultimately 
recover,  and  attain  a  fair  old  age.  Every  surgeon  who  has 
been  much  in  the  post-mortem  room  must  be  familiar  with 
the  fact  that,  in  old  persons  who  have  not  died  of  phthisis, 
repaired  vomicae  and  certification  of  deposits,  probably 
tubercular,  are  not  uncommonly  found.  I  am  quite  certain 
that  there  are  many  sufferers  from  lung  affections  compli- 
cated by  fistula,  who,  because  they  are  said  to  be  phthisical, 
have  nothing  done  for  the  cure  of  their  fistulse,  and  whose 
lives,  in  consequence,  are  rendered  much  more  wearisome 
and  wretched  than  they  might  have  been  if  the  operation 
had  been  judiciously  performed. 

For  my  own  part,  I  do  not  think  we  have  many,  if  any, 
clinical  facts  tending  to  show  that  the  operation  for  fistula 
in  phthisical  patients  renders  the  lung  affection  worse,  or 
makes  it  more  rapidly  progressive.  In  saying  this  I  must 
not  be  understood  to  advocate  wholesale  indiscriminate 
operations  upon  tuberculous  patients  ;  but  I  mean  that  if 
care  be  taken  in  the  selection  of  the  proper  cases,  avoiding 
interference,  it  possible,  with  rapidly  advancing  phthisis,  and 
the  operation  be  performed  discreetly,  at  the  right  time  of 
the  year,  and  with  favorable  surroundings,  the  patients  will 
generally  do  well,  and  be  benefitted  and  not  damaged,  by 
the  cure  of  their  rectal  malady. 

I  have  had  several  cases  which  certainly  at  first  sight 
appeared  to  contradict  what  I  have  just  stated,  and  I  will 
relate  an  example  : 

A  man,  set.  35,  was  admitted  into  St.  Mark's  Hospital  in 
the  spring  of  1867.  He  was  not  absolutely  an  unhealthy 
looking  man,  but  he  was  delicate  ;  he  was  dark  and  hirsute, 
moderately  well  nourished  ;  the  chest  was  fully  developed, 
there  was  no  dullness  on  percussion.  He  had  never  spat 
blood,  but  was  very  liable  to  cold,  and  always  had  a  winter 
cough.  He  had  a  fistula  of  the  blind  internal  variety,  which 
caused  him  a  good  deal  of  suffering,  the  aperture  in  the 
bowel  being  large  and  open. 

Now,  had  this  man  not  been  in  much  pain,  in  all  proba- 
bility I  should  not  have  operated  upon  him,  or,  at  all  events, 
I  should  have  postponed  doing  anything  until  the  summer 
had  more  advanced,  as  I  really  did  not  at  all  like  the  look  of 
him,  but  I  thought  his  case  warranted  an  operation,  the  more 
especially  as  it  did  not  seem  that  a  severe  one  was  necessary. 


FISTULA   IN    CONJUNCTION    WITH    PHTHISIS.  5 1 

Three  days  after  the  operation  he  was  attacked  with  diffi- 
culty of  breathing,  and  on  examination  it  was  found  that 
there  was  pneumonia  of  the  upper  part  of  the  right  lung  ; 
two  days  later  than  this  he  had  an  acute  attack  of  haemoptysis; 
after  a  time  he  got  better,  but  there  was  evidence  of  break- 
ing down  of  lung  tissue.  As  soon  as  possible  I  sent  him  out 
of  the  hospital  to  go  into  the  country  ;  he  returned  much 
better,  with  the  fistula  fairly  healed,  but  I  am  afraid  that,  as 
far  as  his  chest  was  concerned,  he  was  in  a  bad  way. 

Altogether,  I  have  had  twenty-five  such  cases,  in  hospital 
practice,  exactly  resembling  the  one  I  have  related,  so  much 
so,  indeed,  that  it  is  unnecessary  to  give  them  in  detail.  The 
general  circumstances  are  these  :  A  fistula,  in  a  not  very 
consumptive-looking  patient,  suspicious  appearance  and 
history  being  all  that  can  be  made  out.  The  patient  is  oper- 
ated upon,  and  in  four  or  five  days  inflammation  of  a  lung 
and  haemoptysis  set  in,  this  being  in  nearly  all  the  cases  the 
first  attack.  Now,  one  is  not  unnaturally  led  to  conclude 
that  the  operation  is  the  active  cause  of  the  sudden  accession 
of  the  luug  symptoms  in  these  cases  :  but  after  all  it  may 
not  be  so  ;  there  are  other  factors  to  be  considered.  These 
may  be  mentioned :  the  natural  excitement  preceeding  and 
attending  the  operation  ;  the  effect  of  anaesthetics  ;  the  differ- 
ent, and  probably  colder  and  "  draughty  "  air  of  the  hospital 
wards  ;  and  the  sudden  taking  to  the  recumbent  position,  by 
which,  in  lungs  predisposed  to  disease,  hypostatic  engorge- 
ment may  be  readily  set  up,  and  pneumonia  follow.  This 
last  I  thiiik  a  very  important  element  in  the  pneumonia  ; 
and  from  this  I  draw  a  lesson — never  confine  your  patients 
who  have  a  consumptive  tendency  entirely  to  bed.  I  let 
them  recline  on  the  sofa,  and  sit  on  air  cushions,  from  the 
day  of  the  operation,  and  I  really  think  this  precaution  has 
a  great  deal  to  do  with  the  result.  You  may  accept  it  as  a 
fact  that  phthisical  hospital  patients  do  not  do  nearly  so  well 
as  phthisical  private  patients  ;  and  good  feeding,  nursing, 
and  the  comforts  of  a  home,  may  be  credited  to  a  great 
extent  with  the  causation  of  the  difference. 

Those  gentlemen  who  object  to  operating  in  any  case 
upon  a  phthisical  patient,  give  different  and  rather  contra- 
dictory reasons  for  their  objections.  Some  say,  "  Do  not 
operate,  for  the  wound  will  not  heal,  and  the  increased  dis- 
charge will  be  detrimental  ;  "  others,  "  The  healing  of  the 
fistula  will  be  injurious  to  the  patient,  as  the  discharge  pre- 
vents or  retards  the  progress  of  the  chest  affection./'     \  h.^ve. 


52  FISTULA   IN   CONJUNCTION    WITH   PHTHISIS. 

this  remark  to  make  here  :  that  when  a  fistula  has  kindly 
healed,  I  never  knew  a  phthisical  patient  to  be  directly  the 
worse  for  it  ;  /.  ^.,  I  have  never  seen  the  chest  affection 
aggravated  or  suddenly  get  worse  on  the  closing  up  of  the 
wound.  I  think  the  idea  that  the  discharge  retards  the  pro- 
gress of  the  lung  disease  is  rather  the  remnant  of  the  old 
doctrine  of  issues,  setons,  and  derivatives,  than  a  positive 
fact. 

Although  I  say  that  hospital  patients  do  not  as  a  rule  do 
well,  yet  I  have  had  many  satisfactory  results,  even  where 
such  could  hardly  have  been  anticipated.  I  will  detail 
some  : 

A  man,  aged  29,  was  admitted  into  the  hospital,  under  my 
care  ;  he  had  decided  dullness  at  the  apex  of  the  left  lung, 
and  had  spat  blood  frequently,  and  always  had  winter  cough. 
He  had  a  complete  fistula,  with  a  very  patulous  and  large 
internal  orifice,  into  which  faeces  were  constantly  passing, 
and  he  consequently  suffered  much,  and  was  very  anxious 
to  obtain  relief.  On  this  ground  I  determined  to  operate. 
I  did  not  confine  him  to  bed  more  than  a  few  days.  I  fed 
him  well,  and  gave  him  cod-liver  oil  and  tincture  of  muriate 
of  iron  during  the  treatment,  and  I  kept  him  in  the  hospital 
only  nine  days.  He  did  very  well,  the  wound  healed,  and 
as  I  have  seen  him  since,  I  know  that  his  chest  affection  has 
not  progressed. 

Here  is  a  very  favorable  case  which,  by  a  little  cautious 
treatment,  did  well  in  the  end  : 

A  police  constable,  aged  29,  came  to  St.  Mark's  in  the 
summer  of  1867  ;  eight  weeks  previously  he  had  been 
operated  upon  for  fistula  at  St.  Mary's  Hospital.  He  was 
undoubtedly  consumptive  ;  some  time  ago  had  haemoptysis  ; 
he  sweated  at  night,  and  was  very  thin  and  feeble.  On 
examination  an  unhealthy  wound  was  to  be  seen  involving 
the  bowel  ;  the  edges  overhung,  were  livid,  and  irregularly 
ulcerated;  the  mucous  membrane  of  the  bowel  was  under- 
mined to  the  extent  of  two  inches  upward.  A  deep  incision 
had  been  made  through  the  sphincter,  and  he  had  no  power 
to  retain  wind,  or  his  motions  if  at  all  relaxed.  He  coughed 
a  good  deal,  and  expectorated  freely;  he  was  very  depressed 
in  spirits.  It  is  difficult  to  conceive  a  more  lamentable  fail- 
ure of  an  operation;  he  was  in  all  respects  materially  worse 
for  what  had  been  done.  I  scarcely  think,  had  I  seen  the 
man  at  first,  I  should  have  interfered  with  him  at  all.  The 
question  was,  .what  could  be  done.     Finding  that  he  had 


FISTULA    in'  conjunction    WITH    PHTHISIS.  53 

friends  in  the  country  I  advised  his  going  away,  and  told 
him  to  live  in  the  open  air  all  day  long,  to  drink  as  much 
milk  and  cream  as  his  stomach  would  digest,  and  to  take  a 
teaspoonful  of  cod-liver  oil,  and  fifteen  drops  of  the  muriated 
tincture  of  iron,  three  times  in  the  day.  He  had  never  been 
able  to  take  the  oil,  but  I  managed  to  overcome  his  repug- 
nance by  giving  him  one  drop  of  nitro-benzole  with  every 
dose,  for  which  hint  I  am  indebted  to  my  friend.  Dr.  Stone, 
of  St.  Thomas'  Hospital.  The  patient  came  back  in  about 
six  weeks  very  much  improved  in  general  health;  he  had 
gained  weight  and  strength.  His  wound  looked  healthier, 
but  intrinsically  was  in  much  the  same  condition.  I  now 
did  not  dare  to  take  him  into  the  hospital,  fearing  the  con- 
finement and  air;  but  I  thought  something  might  be  done 
to  alleviate  his  condition;  so  I  paired  off  the  overhanging 
and  devitalized  edges  of  the  skin,  and  laid  open  the  sinus 
under  the  mucous  membrane;  I  did  not  confine  him  to  bed 
at  all.  A  few  days  after  doing  this  I  painted  over  the  slug- 
gish base  of  the  wound  with  blistering  fluid,  and  thus  got 
the  whole  wound  to  granulate.  After  about  five  weeks  it 
healed;  he  recovered  very  considerable  power  in  the 
sphincter,  and  altogether  was  in  a  wonderfully  more  favor- 
able condition  than  when  I  took  him  in  hand.  To  show 
what  an  improved  state  of  health  he  was  in  I  can  state  that 
he  was  able,  the  whole  of  the  following  winter,  to  take  his 
turn  of  night  duty,  without  being  once  on  the  sick  list. 

There  is  a  circumstance  which  occasions  me  sometimes  to 
interfere  in  a  case  of  fistula  in  phthisical  patients,  and  that  is, 
the  mental  depression  which  the  rectal  affection  creates. 
Frequently  the  sufferer  thinks  much  more  about  his  fistula 
than  he  does  about  what  he  calls  "his  little  cough,"  and  is 
quite  dismayed  and  brought  to  dispair  when  you  tell  him 
that  you  cannot  do  anything  to  cure  him.  I  am  certain  that 
few  things  conduce  more  to  the  rapid  progress  of  phthisis 
than  mental  anxiety  and  loss  of  hope. 

As  illustrating  this  I  will  relate  the  case  of  a  young  man 
named  Henry,  who  came  to  me  at  St.  Mark's  in  the  year 
1866  :— 

He  was  in  great  mental  distress  because  of  a  fistula,  for 
which  a  well-known  surgeon  had  told  him  nothing  could  be 
done,  as  he  was  consumptive.  It  was  true  that  this  man  had 
suffered  from  haemoptysis  some  time  ago,  and  looked  far 
from  being  a  promising  patient ;  moreover,  his  family  history 
was  unsatisfactory.     On  examing  him  I  found  that  his  fistula 


54  FISTULA    IN    CONJUNCTION    WITH    PHTHISIS. 

was  evidently  a  phlegmonous  one,  and  not  scrofulous,  /.  e.  it 
began  as  an  abscess,  ran  an  acute  course,  opened  externally, 
and  did  not  communicate  with  the  bowel,  so  I  thought  I 
could  operate  upon  him  with  safety.  The  mere  fact  of  his 
belief  that  he  would  get  rid  of  a  most  troublesome  and 
annoying  disorder  rallied  him  at  once.  The  day  following  the 
operation  he  looked  much  better  than  he  had  done  before  it, 
and  without  any  interruption  he  quickly  got  well.  I  watched 
the  man  for  more  than  twelve  montns,  and  most  assuredly 
his  lung  symptoms  had  made  no  marked  advance. 

I  relate  cases  which  occurred  some  years  since,  because  we 
have  the  opportunity  of  seeing  how  they  terminated  : — 

In  the  spring  of  1866  I  operated  upon  a  gentleman,  a 
patient  of  Mr.  Burroughs,  of  Lee.  He  was  decidedly  but  not 
hopelessly  phthisical ;  the  undermining  of  skin  in  this  case 
was  very  considerable,  and  he  suffered  so  much  that  I  had 
not  the  least  doubt  about  the  propriety  of  attempting  to 
relieve  him.  The  wound  was  large,  but  we  had  really  no 
difficulty  in  getting  it  to  heal.  I  saw  a  relative  of  this  patient 
lately,  who  informed  me  that  he  continued  well  and  had  no 
return  of  the  fistula.  I  believe  in  this  case  the  chest  symptoms 
were  absolutely  benefited  by  the  operation. 

A  young  man  was  brought  to  me  by  his  friends  in  August, 
1864.  He  was  twenty  years  of  age,  and  a  decidedly  phthisical 
appearance  ;  he  had  a  circumscribed  flush  on  his  cheeks  ; 
was  thin,  and  had  a  rapid,  feeble  pulse  ;  he  was  a  railway 
clerk,  and  had  been  leading  a  rather  irregular  life  for  twelve 
months  previous  to  his  present  illness  ;  he  had  never  suffered 
from  haemoptysis  to  any  extent,  but  had  spat  mucus  streaked 
with  blood  not  infrequently.  There  was  some  dullness  over 
the  apex  of  the  left  lung,  and  feeble  inspiratory  murmur. 
He  took  cold  on  the  slightest  provocation  ;  he  had  lost  a 
sister  by  consumption,  and  also  his  maternal  aunt  ;  his  mother 
was  far  from  a  healthy-looking  woman  ;  but  his  father  was 
strong  and  had  no  tendency  to  pulmonary  disease.  This  was 
a  case  I  would  willingly  not  have  interfered  with,  but  the 
patient  was  suffering  so  much  that  I  determined  to  try,  after 
improving  his  health,  what  I  could  do  for  him.  The  fistula 
commenced  last  Christmas,  as  an  abscess,  which  opened 
spontaneously.  When  I  first  saw  him,  he  had  a  sinus  on 
one  side  of  the  bowel  and  an  unopened  abscess  on  the  other 
side,  and  was  suffering  a  good  deal  of  pain.  The  abscess  I 
opened  at  once.  I  put  him  on  cod-liver  oil  and  tinct.  ferri 
muriatis,  and  soon  sent  him  away  into  the  country.      He 


FISTULA    IN    CONJUNCTION    WITH    PHTHISIS  55 

returned  very  much  better  in  health,  but  the  sinus  had  bur- 
rowed behind  the  anus  and  joined  the  abscess  I  had  opened, 
thus  forming  the  not  uncommon  horse-shoe  fistula.  He  was 
now  importunate  for  something  to  be  done,  and  although 
I  was  very  dubious  about  the  result,  I  yielded  to  his  wishes. 
There  was  one  good  point  in  his  case  which  encouraged  me, 
and  that  was,  the  discharge  was  tolerably  healthy.  On  the 
23d  of  September  I  operated,  not  making  more  incisions 
than  were  necessary,  but  freely  removing  the  overlapping 
edges  of  skin.  He  took  full  diet — wine,  beer,  and  anything 
he  fancied — from  the  day  of  the  operation  and  (with  the 
exception  of  a  little  burrowing  under  the  skin  toward  the 
perineum,  which  I  was  obliged  to  lay  open)  he  made  a 
good  recovery.  On  the  loth  of  November  he  was  quite 
well,  and  was  weighed,  and  showed  an  increase  of  fourteen 
pounds  since  the  operation.  This  lad  died  of  phthisis  three 
years  after.  The  fistula  never  recurred,  and  for  more  than 
two  years  he  enjoyed  fair  health. 

In  the  year  1867  I  operated  upon  a  patient  who  was  a 
very  delicate  and  decidedly  consumptive  person  ;  he  suffered 
much  from  winter  cough,  and  had  spat  blood  several  times  ; 
there  was  a  history  of  phthisis  in  his  family.  His  fistula 
was  a  complete  one  and  caused  him  a  great  deal  of  pain  and 
inconvenience,  interfering  most  materially  with  his  taking 
any  walking  exercise,  I  operated  upon  him,  and  was  a  few 
weeks  later  compelled  to  lay  open  another  sinus,  which  had 
either  formed  since  or  been  overlooked  by  me.  The  wounds 
were  slow  in  healing,  and  required  a  good  deal  of  attention, 
but  finally  they  cicatrized  soundly,  and  the  patient's  health 
was  much  benefited  by  his  freedom  from  pain  and  his 
renewed  capability  of  walking.  I  saw  this  gentleman  very 
lately  ;  he  is  still  delicate,  but  enjoys  a  fair  amount  of  health, 
and  the  fistula  remains  still  healed  ;*  most  assuredly  he 
has  not  been  damaged  by  what  was  done  for  him. 

I  operated  some  four  years  ago  upon  a  patient  who  was 
under  the  care  of  Dr.  Palfrey  and  Dr.  G.  F.  Fowler  of 
Kennington.  This  gentleman  had  undoubted  phthisis,  with 
vomicae  in  his  lungs,  and  at  the  same  time  he  suffered  so 
much  from  an  internal  fistula  with  a  large  opening  that  I  felt 
compelled  to  try  and  relieve  him.  Accordingly,  with  the 
concurrence  of  Drs.  Palfrey  and  Fowler,  I  opened  the  fistula. 
The  wound  slowly  but  surely  healed,  and  from  the  day  of 

*  Eleven  years  after  the  operation. 


56  FISTULA    IN    CONJUNCTION    WITH    PHTHISIS. 

the  operation  he  lost  his  pain,  and  lived  about  two  years  in 
comparative  comfort — a  longer  time  than  was  anticipated  by 
his  medical  attendants. 

I  saw,  in  conjunction  with  Dr.  Wilson  Fox,  a  gentleman 
about  28  years  of  age,  who  had  been  some  time  in  India,  and 
who  had  suffered  from  pleurisy  and  pneumonia,  associated 
with  the  deposit  of  tubercle  ;  he  also  had  a  complete  fistula, 
which  gave  him  great  inconvenience,  and  at  times,  pain.  He 
was  very  anxious  to  have  something  done  for  this,  and  Dr. 
Fox,  as  his  lung  condition  was  stationary  and  no  active  disease 
present,  was  of  opinion  that  there  was  no  objection  to  an 
operation  on  the  fistula  ;  I  therefore  cut  through  the  sinus 
with  the  elastic  ligature  without  occasioning  the  patient  any 
pain  or  confining  him  more  than  forty-eight  hours  to  his 
room  ;  four  days  sufficed  for  the  ligature  to  cut  through,  and 
the  wound  soon  healed,  the  patient  experiencing  great  com- 
fort. After  about  eight  months  he  caught  a  cold,  and  his 
chest  symptoms  recurred  with  much  cough,  and  the  cicatrix 
of  the  wound  in  the  part  near  the  anus  broke  down,  but  this 
did  not  trouble  him  much,  and  from  time  to  time  the  wound 
healed  and  reappeared  ;  but  there  was  no  doubt  in  the  mind 
of  the  patient  as  to  the  advantage  of  the  operation,  and  Dr. 
Fox  eould  not  «ay  that  any  disadvantage  had  accrued.  The 
patient  was  one  of  those  men  who  never  will  take  care  of 
themselves,  and  who  habitually  smoke  and  drink  too  much. 
With  all  those  drawbacks,  two  years  after  the  operation  he 
was  still  living. 

The  question  of  cough  is  a  very  important  one  when 
weighing  the  probabilities  of  an  operation  doing  well  or  ill. 
I  believe  that  severe  or  frequent  cough,  no  matter  from  what 
it  arises,  is  most  inimical  to  the  well-doing  of  the  patient. 

A  medical  man  came  from  the  country  a  short  time  ago  to 
be  operated  upon  by  me  for  a  complete  fistula  ;  there  was 
not  the  least  suspician  of  phthisis,  but  he  had  a  bad  cough. 
I  advised  him  to  get  rid  of  his  cough  before  being  operated 
on,  but  he  was  anxious  to  get  the  matter  over,  and  thought 
his  cough  would  not  trouble  him.  However,  though  the 
fistula  was  a  simple  one,  I  could  not  get  it  to  heal  until  his 
cough  was  cured,  and  he  was  four  weeks  in  town,  whereas, 
under  favorable  circumstances,  fourteen  days  would  have 
been  ample  time  to  have  effected  the  cure. 

From  this  arises  a  maxim  I  always  adhere  to  :  never,  if 
you  can  possibly  help  it,  operate  upon  a  phthisical  patient 
when  the  cough  is  constant  ;  and  never  operate  in  unfavorable 


FISTULA   IN   CONJUNCTION   WITH   PHTHISIS.  57 

weather.  If  your  patient  is  in  good  circumstances  send  him 
to  Brighton  or  Hastings,  or  some  other  salubrious,  genial 
place,  and  perform  the  operation  there.  You  will  find  he 
will  get  well  in  less  time,  and  possibly  save  you  anxiety. 

Assuming,  as  I  think  we  safely  may,  that  many  patients, 
the  subjects  of  fistula,  have  also  a  tendency  or  predisposition 
to  phthisis,  it  will  not  be  unprofitable  to  consider  for  a 
moment  why  this  should  be  the  case.  The  conjunction  has 
been  ascribed  to  tuberculous  ulceration  of  the  bowel,  and, 
no  doubt,  in  some  cases  this  opinion  is  correct.  I  am  quite 
sure  now  that  many  cases  of  incurable  ulceration  in  the 
rectum  are  tubercular,  this  portion  of  the  bowel,  when 
examined  after  death,  presenting  precisely  similar  conditions 
to  those  which  are  found  in  other  parts  of  the  intestine  well 
known  to  be  thus  affected.  The  ulcers  are  deep,  and  spread 
at  the  edges,  joining  others,  and  undermining  the  mucous 
membrane,  leaving  broad  or  narrow  bridges.  In  this  form  of 
ulceration,  as  a  rule,  pulmonary  phthisis  does  not  co-exist,  or 
at  all  events,  only  shows  itself  very  late  in  the  disease.  In 
the  case  of  a  young  gentleman  I  saw  several  times  with  Sir  J. 
Paget  and  Sir  William  Gull,  the  ulceration  was  very  marked, 
and  extended  high  up  the  rectum,  but  no  chest  affection 
became  apparent  until  three  years  had  elapsed  from  the  com- 
mencement of  the  bowel  disease.  In  the  many  cases  of  phthisis 
I  have  seen,  in  which  Astula  formed,  there  has  been  no 
diffused  ulceration  of  the  rectum,  possibly  because  the  disease 
spent  itself  mainly  upon  the  lungs  ;  and  in  the  case  of  tubur- 
culous  ulceration  of  the  rectum,  anal  fistulas  are  not  common. 

The  rule,  in  my  opinion,  is,  that  fistula  in  patients  who 
have  a  predisposition  to  pulmonary  consumption  commences 
by  a  breaking  down  of  the  connective  tissue  beneath  the 
mucous  membrane  of  the  rectum  ;  thus  a  small  abscess  is 
formed,  and  this  makes  its  way  into  the  bowels  very  rapidly, 
leaving  a  large,  patulous  aperture.  Therefore,  I  think  we 
may  safely  say  that  the  same  condition  of  health  or  constitu- 
tion which  renders  a  patient  liable  to  pulmonary  affections 
generally,  renders  him  also  prone  to  fistula.  These  people 
are  usually  thin  and  ill-nourished,  and  have  very  little  power 
of  resistance  against  injurious  influences ;  inflammation, 
which  in  robust  individuals  would  result  only  in  the  effusion 
of  plastic  material,  in  them  terminates  in  the  production  of 
numerous  and  very  perishable  cells,  which  readily  form  them- 
selves into  purulent  collections,  especially  in  lax  tissues.  Pro- 
bably, I  should  say,  the  want  of  fat  in  the  ischio-rectal  fossa 


58  FISTULA    IN    CONJUNCTION    WITH    PHTHISIS. 

and  its  neighborhood  dispones  to  the  formation  of  an  abscess 
there.  The  veins  have  to  sustain  a  considerable  column  of 
blood,  and  they  are,  moreover,  exceedingly  ill  supported,  so 
that  local  congestions  and  feeblensss  of  circulation  must  be 
a  common  condition.  I  am  inclined  to  think  that  these 
general  causes  are  usually  sufficient  to  explain  the  phenomena 
without  any  reference  to  tuberculous  depositions. 

Fistulae  in  persons  of  a  phthisical  tendency  are  marked  by 
certain  peculiarities  which  1  think  important  to  notice.  Some 
have  been  already  casually  mentioned,  but  I  will  here  state 
them  clearly. 

They  have  a  disposition  to  undermine  the  skin  and  mucous 
membrane  with  remarkable  rapidity,  but  not  to  burrow 
deeply. 

The  internal  aperture  is  almost  always  large  and  open;  on 
passing  your  finger  into  the  bowel  you  can  feel  it  most  dis- 
tinctly, often  the  size  of  a  threepenny  piece. 

The  external  opening  is  also  frequently  large  and  ragged, 
not  round  ;  it  is  irregular  in  form,  and  surrounded  by  livid 
flaps  of  skin  ;  when  you  pass  your  probe  into  this  aperture 
you  can  swxep  it  round  over  an  area  of  more  than  an  inch, 
and  not  infrequently  the  skin  is  so  thin  that  you  can  see  the 
probe  beneath. 

This  is  a  very  different  condition  from  that  of  the  external 
orifice  of  a  fistula  in  a  healthy  persbn,  which  is  usually  small 
and  pouting,  and  the  skin  is  not  detached,  to  any  extent, 
from  the  underlying  structures. 

The  discharge  is  thin,  watery,  and  curdy,  very  rarely  really 
purulent. 

The  sphincter  muscles  are  almost  invariably  very  weak. 
When  you  introduce  the  finger  into  the  bowel  you  are  hardly 
sensible  of  any  resistence  being  offered.  I  think  this  a  most 
important  indication  of  constitutional  weakness,  and  from  it 
I  derive  this  practical  lesson  :  When  operating  upon  a  patient 
with  phthisical  proclivity  interfere  as  little  as  possible  with 
the  sphincter  muscles,  especially  the  internal.  If  you  divide 
the  spincter,  much  incontinence  of  faeces  will  almost  cer- 
tainly result. 

It  is  common  to  observe,  in  these  patients,  much  longish, 
soft,  silky-looking  hair  around  the  anus. 

WitYi  any  of  these  peculiarities  strongly  marked,  I  am 
always  suspicious  of  my  patient's  strength;  with  all  of  them 
or  several  of  them  present,  I  feel  certain  of  his  condition 
and  act  accordingly. 


FISTULA    IN    CONJUNCTION    WITH    PHTHISIS.  59 

I  should  say,  from  my  experience,  if  you  have  a  phthisical 
patient  suffering  from  a  fistula  which  gives  him  much  pain  or 
inconvenience,  by  taking  certain  precautions  you  may  relieve 
him  of  it  without  running  any  risk  of  damaging  him.  When 
a  case  of  this  kind  comes  to  me,  I  am  never  in  a  hurry  to 
operate.  I  like  to  watch  the  patient  for  a  little  while,  and 
observe  whether  the  lung  disease  is  advancing,  and  also  to 
find  out  if  the  cough  is  constant  ;  often  these  patients  will 
assert  that  they  cough  very  little,  when  their  friends  notice 
that  they  do  so  almost  perpetually.  Wait,  if  you  can,  for 
genial  weather,  when  your  patient  need  not  be  confined  to 
a  close  room.  As  to  the  operation,  I«have  already  said  that, 
although  it  must  be  thorough,  you  should  interfere  with  the 
sphincter  as  little  as  you  can,  and,  fortunately,  it  is  not 
usually  necessary  to  cut  deeply,  as  the  sinuses  are  mostly 
superficial.  After  the  operation  let  the  patient  have  good 
diet ;  by  all  means,  plenty  of  cream  and  milk  ?  if  he  can 
take  it^  he  may  have  a  little  cod-liver  oil  and  steel,  and 
quinine,  separate  or  combined  ;  do  not  confine  him  to  bed  ; 
let  him  lie  on  a  mattress  ;  if  you  can  manage  it,  let  the  bed- 
room face  south  or  west,  and  get  plenty  of  fresh  air  into  the 
room,  the  patient  lying,  well  covered  up,  on  a  couch  by  the 
open  window,  for  hours,  in  fact,  nearly,  all  day.  Do  all  you 
can  to  keep  him  amused  and  cheerful ;  avoid  poulticing  the 
wound  ;  disturb  it  as  little  as  possible,  keep  it  clean  by 
gently  syringing  with  a  solution  of  carbolic  acid  (i  in  50), 
night  and  morning,  and  well  dry  afterward;  dress  with  wool; 
ointments,  as  a  rule,  do  not  suit,  but  ^astringents  are  useful ; 
the  compound  tincture  of  benzoin  agrees  very  well  with 
these  wounds.  Do  not  be  in  a  hurry  to  get  the  bowels  open, 
and  manage  this  rather  by  diet  and  laxatives  than  a  purge  ; 
if  you  set  up  a  diarrhoea  in  these  patients  it  will  give  you 
trouble,  and  delay  the  healing  of  the  wound.  Unless  there 
is  furring  of  the  tongue,  headache,  or  loss  of  appetite,  1  do 
not  think  the  bowels  need  be  relieved  more  than  once  in 
three  or  four  days.  All  these  matters  may  appear  trivial  as 
to  be  almost  unworthy  of  mention,  but  I  am  sure  that  atten- 
tion to  apparent  trifles  will  make  just  the  difference  between 
success  and  failure  with  the  patients  about  whom  I  have  been 
writing. 


6o  HAEMORRHOIDS. 

CHAPTER  VII. 

HiEMORRHOIDS. 

Almost  from  time  immemorial  haemorrhoids  have  been 
divided  into  two  varieties,  viz.:  the  external  and  the  internal, 
often  also  popularly  called  blind  piles  and  bleeding  piles, 
and  this  classification  is  founded  upon  a  true  pathological 
distinction  ;  for,  although  it  may  be  correctly  said  that  exter- 
nal piles  may  and  do  encroach  upon  the  mucous  membrane, 
and  so  are  partially  internal,  and  further,  that  internal  piles 
by  reason  of  frequent  prolapse,  become  more  or  less  external 
yet  in  the  majority  of  cases  the  difference  is  well  marked, 
and  precludes  the  slightest  doubt  as  to  the  diagnosis. 

In  the  external  form  the  observer  will  perceive  that  they 
are  either  the  true  hypertrophies  of  skin,  exaggerations  of  the 
natural  rugose  state  of  the  anus,  or  rounded  and  elongated 
venous-looking  tumors  which  pass  up  into  the  bowel. 

In  the  internal  kind  he  will  observe  that  they  are  tumors 
originating  within  the  anus,  but  which  have  been  forced  down 
outstde,and  even  may  have  put  on  a  pseudo-cutaneous  appear- 
ance, from  exposure,  having  been,  for  more  or  less  time,  sub- 
ject to  the  same  conditions  as  the  skin.  In  addition  to  this, 
he  will  notice  that  there  are  also,  in  very  many  cases,  cuta- 
neous excresences  accompanying  the  internal  piles.  Should 
the  surgeon  still  have  any  doubt  as  to  the  kind  of  hsemorrhoid 
he  has  to  deal  with,  let  him  return  all  the  protruded  part 
that  he  can  within  the  sphincter  ani,  by  gentle  pressure  at 
the  same  time  directing  the  patient  to  retract  or  draw  up  the 
lower  part  of  the  gut.  He  will  then  find  out  what  is  redun- 
dant skin  and  what  is  internal  hsemorrhoid  and  prolapsed 
mucous  membrane  of  the  anus  ;  should  the  whole  mass  be 
irreducible,  it  must  be  treated  as  a  case  of  internal  haemor- 
rhoids. I  have  been  rather  particular  in  these  introductory 
observations,  because  I  have  so  often  seen  considerable 
doubt  in  the  minds  of  practitioners  as  to  the  character  of  the 
affection  they  had  to  combat,  and  a  correct  conclusion 
is  all-important,  especially  if  any  operative  procedure  be 
meditated. 

EXTERNAL    H/EMORRHOIDS. 

These  affections  are  so  prevalent,  that  very  few  persons,  either 
male  or  female,  arrive  at  middle  age  without  having  in  some 


HEMORRHOIDS.  6l 

degree  suffered  from  them.  They  occur  almost  equally  in 
the  robust  and  the  weakly,  in  the  rich  and  the  poor,  in  the 
active  and  sedentary.  No  doubt  some  occupations  and 
modes  of  life  conduce  to  the'production  of  external  haemor- 
rhoids more  than  others,  still  I  repeat,  there  is  no  class  of 
society  or  state  of  constitution  which  can  be  said  to  be  entirely 
exempt.  The  skin  around  the  anus  and  the  mucous  mem- 
brane at  the  verge  of  that  aperture  are  remarkably  delicate 
in  structure,  they  are  also  profusely  supplied  with  nerves  and 
small  vessels;  from  these  facts  it  arises  that  anything  tending 
to  irritate  that  region  may  readily  cause  congestion  and 
inflammation  of  the  part  and  result  in  an  attack  of  piles.  To 
certain  anatomical  peculiarities  of  structure  in  the  rectum 
and  its  viens,  supposed  to  be  the  predisposing  and  also  the 
active  cause  of  haemorrhoids,  I  shall  refer  further  on.  Again, 
obstructions  of  the  liver  or  portal  system,  fecal  accumulations 
or  anything  rendering  the  return  of  blood  from  the  rectum 
difficult,  are  likely  to  conduce  to  the  same  end.  From  this 
we  can  readily  imagine  that  a  great  variety  of  causes  may 
bring  on  an  attack  of  piles;  the  following  may  be  mentioned: 
Constipation,  often  associated  with  chronic  spasm  of  the 
external  sphincter  muscle,  diarrhoea,  too  good  living,  espec- 
ially the  consumption  of  large  quantities  of  meat,  very  coarse 
fare,  indulgence  in  alcoholic  drinks,  excessive  smoking, 
violent  and  prolonged  exertion,  sedentary  occupation,  expos- 
ure to  wet  or  cold,  discharges  from  the  bowel,  resulting  from 
internal  diseases,  the  pressure  caused  by  the  uterus  during 
pregnancy,  uterine  displacement,  friction  from  clothing,  and 
the  use  of  printed  paper  as  a  detergent,  especially  the  cheap 
papers,  from  which  the  ink  comes  off  on  the  slightest  friction 
the  neglect  of  proper  ablutions  (this  is  very  important;  many 
persons  seem  to  forget  that  the  anus  requires  quite  as  much 
washing  as  any  other  part  of  the  body),  straining,  however 
induced  all  these  are  among  the  common  causes,  predisposing 
or  exciting,  of  external  haemorrhoids. 

I  have  already  said  that  two  varieties  of  external  piles  may 
be  recognized;  the  first  ought  to  be  called  hypertrophies  or 
excrescences  of  the  skin  ;  the  second,  sanguineous  venous 
tumors.  When  you  look  at  either  of  these  in  an  uninflamed 
state,  you  would  think  them  harmless  enough  ;  in  the  one 
caee  you  will  observe  around  the  anal  orifice  merely  a  cer- 
tain redundancy  of  the  skin,  forming  little  flaps  or  tabs,  more 
or  less  pendulous,  in  addition  to  the  small  radiating  corruga- 
tions seen  in  the  normal    state  ;  in    the    other  case  you  per- 


62  HEMORRHOIDS. 

ceive  blue  veins,  rather  raised  above  the  surface,  and  running 
up  into  the  bowel,  resembling  indeed,  varicose  veins.  Now, 
these  conditions,  so  innocent  in  their  appearance,  are  prone, 
at  a  very  trifling  provocation,  to  take  an  active  inflammation, 
and  to  cause  the  patient  an  amount  of  suffering  quite  dispro- 
portionate to  the  pathological  appearance. 

Look  at  them  when  inflammation,  set  up  by  any  of  the 
causes  we  have  mentioned,  has  set  in.  These  small  tabs  of 
skin  are  much  increased  in  size  ;  they  may  be  very  swollen 
oedematous,  and  shiny;  they  are  exceedingly  painful  to  the 
touch;  sometimes  they  ulcerate,  or  suppuration  may  take 
place,  if  the  inflammation  runs  very  high,  and  hence  small 
but  painful  little  fistula  arise.  At  times  the  oedema  is  so 
considerable  as  to  extend  into  the  bowel,  and  form  a 
large,  swollen  ring  of  skin  and  everted  mucous  membrane 
all  round  the  anus. 

So  with  regard  to  the  sanguineous  venous  haemorrhoids,  they 
are  swollen  into  ovoid  or  globular,  bluish  tumors,  very  hard, 
exquisitively  painful  ;  they  can  be  pinched  up  between  the 
finger  and  thumbs  from  the  tissues  beneath,  and  they  feel  as  if 
a  foreign  body  were  present  there.  Sometimes,  but  rarely, 
they  can,  by  gentle  pressure,  be  emptied  of  their  contents  ; 
but  this  proceeding  is  not  followed  by  any  benefit  to  the 
patient,  as  in  a  few  hours  they  become  more  painful  and 
larger  than  before.  These  tumors  may  be  single,  or  two  or 
three  may  be  present  at  the  same  time  ;  by  irritation  they 
set  up  spasm  of  the  sphincter  and  levator-ani  muscles,  so  that 
they  are  drawn  up  and  pinched,  thus  adding  much  to  the 
patient's  suffering.  Just  as  he  is  falling  to  sleep  a  spasm 
takes  place,  and  wakes  him  up  ;  in  addition,  there  is  a  con- 
stand  throbbing  and  the  sensation  as  if  a  foreign  body  were 
thrust  into  the  anus  ;  this  excites  the  desire,  every  now  and 
again,  to  attempt  to  expel  it  by  straining,  which,  if  indulged 
in,  of  course,  aggravates  the  pain.  Often  the  patient  cannot 
sit  down,  save  in  a  constrained  attitude,  nor  can  he  walk, 
and  when  he  coughs,  the  succussion  causes  acute  suffering. 
When  the  bowels  act,  and  for  some  hours  afterward,  the  dis- 
tress is  greatly  increased,  and  the  patient,  if  not  absolutely 
confined  to  bed,  is  quite  incapable  of  attending  to  his  busi- 
ness. Accompanying  all  this  there'  is  general  feverishness, 
furred  tongue  and  usually  constipation.  Such,  then,  are  the 
symptoms  of  an  acute  attack  of  external  piles,  and  if  not  a 
serious  matter,  it  is  one  causing  great  worry  and  loss  of  time, 
an  important  point  in  these  hard-working  days.  Moreover,  one 


HAEMORRHOIDS.  63 

invasion  predisposes  to  another.  I  have  known  many  patients 
who  periodically  suffer  what  I  have  described. 

There  is  a  difference  of  opinion  as  to  the  mode  of  forma- 
tion of  these  venous  tumors;  some  consider  them  to  be 
coagulations  of  blood  in  varicose  veins,  others  as  extrava- 
sations into  the  connective  tissue.  It  is  possible  that  both 
these  views  are  correct.  I  am  certain  that  I  have  often 
found  clots  contained  in  a  distinct  sac,  formed  of  inflamed 
and  condensed  areolar  tissue,  without  any  communication 
with  a  vein  that  the  most  careful  examination  could  detect; 
and,  on  the  other  hand.  I  have,  in  some  cases  been  able  to 
squeeze  the  blood  out  of  the  tumors  into  the  vein.  It  may 
be  that  in  the  early  stage  of  the  disease  the  pile  is  simply  a 
varicosity  of  the  vein,  but  soon  inflammation  shuts  the  clot 
off  from  the  trunk;  and  after  a  time,  and  repeated  inflam- 
mations the  clot  becomes  enclosed  in  a  sac;  but,  after  all, 
the  question  to  my  mind  does  not  seem  a  very  impor- 
tant one  as,  it  in  no  way  influences  the  treatment  to  be 
adopted. 

It  is  very  desirable  to  ncftice  the  earliest,  or  rather  the 
premonitory,  symptoms  of  one  of  these  attacks,  as  by  this 
knowledge  it  may  possibly  be  warded  off,  or  at  all  events, 
much  mitigated.  Not  infrequently  a  little  extra  eating  and 
drinking,  without  any  absolute  excess,  is  the  exciting  cause; 
an  indulgence  in  effervescing  wines,  or  full-bodied  ports,  or 
new  spirits,  being  especially  dangerous.  The  earliest  symp- 
tom is  a  sensation  of  fullness  or  plugging  up,  and  slight  pul- 
sation in  the  anus;  there  is  also  a  tendency  to  constipation, 
inducing  a  little  straining;  this  is  frequently  followed  by 
itching  of  a  very  annoying  character,  coming  on  when  the 
patient  gets  warm  in  bed,  keeping  him  awake  for  some  time, 
and  inducing  him  to  scratch  the  part.  In  the  morning  he 
finds  the  anus  a  little  swollen  and  tender,  and  if  he  be  an 
observant  person  with  regard  to  himself,  he  will  notice  after 
a  motion  a  slight  stain  of  blood.  Now,  this  may  all  pass  off 
with  the  simplest  care  and  the  slightest  medication;  but  if 
the  patient  neglects  himself,  it  will  surely  be  the  precursor  of 
a  more  or  less  severe  attack. 

The  treatment  in  such  a  case  should  be  abstinence 
from  active  exercise,  rather  spare  diet,  well-cooked  vegeta- 
bles and  fish,  not  much  meat,  no  beer  or  spirits,  and  wine  is 
not  desirable;  if  the  patient  must  take  some  stimulant,  a 
glass  of  light  claret,  with  Seltzer  or  Vichy  or  Vals  water,  will 
be  the  best  beverage.    If  he  is  a  smoker,  he  must  cut   down 


64  HAEMORRHOIDS. 

his  usual  allowance;  smoking  often  causes  a  sympathetic 
irritation  of  the  throat  and  rectum.  He  may  take  a  warm 
bath  or  a  Turkish  bath,  and  should  wash  the  anus  night  and 
morning  with  warm  water  and  Castile  soap;  after  this,  apply 
some  glycerine  and  tannic  acid,  or  some  calomel  ointment, 
or  a  lotion  composed  of  one  teaspoonful  of  the  Liq.  Plumbi- 
Subacetatis,  added  to  a  wineglass  of  fresh  milk,  which  is 
very  soothing.  As  to  medicines,  he  may  take  a  Plummer's 
pill,  with  a  little  taraxacum  and  belladonna,  for  two  or  three 
nights,  at  bedtime;  and  in  the  morning,  fasting,  some  effer- 
vescing citrate  of  magnesia,  or  this  draught,  which  I  have 
found  very  useful  on  many  oecasions: — 

J^-  •     Liq.  Magnes.  Carb 5  ss 

Potassae  Bicarb 3  j 

Syrup,  or  Tinct  Sennae 3  ij 

Spt.  ^ther.  Nit 3  ss 

Aquae  purae ad |  ij. 

One-third  of  a  tumbler  of  Friedrichshall  water,  taken  fast- 
ing, with  twice  as  much  warm  water,  or  Carlsbad  salts,  will 
also  have  a  good  effect. 

If  the  case  be  neglected,  and  advice  is  not  sought  until 
active  inflammation  has  set  in,  and  the  symptoms  I  have 
described  are  in  full  force,  you  will  save  your  patient  much 
time,  pain,  and  after  trouble,  by  snipping  off  the  inflamed, 
cutaneous  excrescences,  or  in  the  case  of  sanguineous 
tumors,  by  laying  them  freely  open.  The  tabs  of  skin  may 
may  be  frozen  by  the  etherizer,  seized  with  a  pair  of 
toothed  forceps,  and  quickly  snipped  off  with  a  pair  of 
strong  scissors;  the  pain  soon  ceases  and  the  wounds  heal 
readily  under  any  simple  dressing.  Care  must  be  taken  not 
to  recklessy  cut  away  too  much  skin,  or  contraction  will  fol- 
low; you  must,  therefore,  not  make  quite  a  clean  sweep  of 
it,  but  take  off  a  portion  only;  that  which  is  left  will  con- 
tract in  the  process  of  healing.  The  best  method  of  open- 
ing the  venous  swelling  is  as  follows:  Pinch  up  the  tumor 
gently  between  the  finger  and  thumb  of  the  left  hand,  trans- 
fix its  base  with  a  curved  bistoury,  and  cut  out;  at  the  same 
moment,  by  pressure  with  the  finger  and  thumb,  the  clot 
may  be  extruded;  place  a  piece  of  fine  cotton  wool  at  the 
bottom  of  the  sac,  and  the  operation  is  completed;  the  pain 
soon  subsides,  and  the  patient  makes  a  speedy  convales- 
cence. The  incision  should  be  made  in  the  direction  of  the 
radiating  folds  of  the  anus,  in  order  to  facilitate  the  contrac- 


HAEMORRHOIDS.  65 

tion  of  the  skin.  If  these  sanguineous  tumors  are  not  inter- 
fered with,  the  blood  in  them  will,  in  time,  become  absorbed, 
and  they  may  ultimately  form  the  cutaneous  flaps  already 
described.  It  is  always  well  in  these  cases  to  ascertain,  by 
means  of  an  injection,  whether  there  be  any  internal  piles 
associated  with  the  external;  if  so,  they  must  be  attended  to, 
or  the  patient  will  probably  be  made  worse  by  any  operation 
on  the  external  haemorrhoids. 

If  the  patient  will  not  submit  to  the  operative  treatment  I 
have  recommended,  the  swollen  parts  should  be  well  smeared 
with  extract  of  belladonna  and  extract  opium,  equal  parts, 
and  a  warm  poultice  applied.  This,  in  many  cases,  gives 
very  speedy  relief,  and,  as  a  rule,  is  much  more  efficacious 
than  cold  applications.  But  sometimes  it  happens  that  cold 
is  found  by  the  patient  to  be  more  soothing;  in  that  case  a 
lotion  of  Goulard  water,  with  extract  of  opium  and  bella- 
donna, is  useful,  or  ice  may  be  pretty  constantly  applied.  It 
does  not  answer  to  freeze  the  piles  with  the  ether  spray,  as  I 
have  seen  recommended,  for  as  soon  as  the  cold  goes  off  the 
pain  it  worse  than  ever.  I  have  never  seen  much  benefit 
derived  from  leeching.  Some  surgeons  have  insisted  that 
the  inflammation  should  be  reduced  before  removing 
the  piles  by  excision.  I  do  not  think  there  is  any  need 
for  this  delay;  certainly  the  parts  are  very  tender  and 
sensitive,  but  the  pain  can  be  overcome  by  thorough  freez- 
ing, and  I  am  convinced  that  convalescence  is  much  has- 
tened by  the  removal  of  the  inflamed  and  oedematous  tis- 
sues, and,  as  far  as  my  experience  goes,  no  danger  of  any 
kind  need  be  apprehended  from  the  operation  if  it  be  prop- 
erly performed.  I  much  too  often  see  these  cases  treated 
by  drastic  purges  and  gall-ointment;  this,  I  am  bound  to 
s.ay,  is  not  good  practice;  in  the  active  stage  it  is  harmful  to 
the  patient. 

I  have  said  that  one  attack  of  external  haemorrhoids  pre- 
disposes to  another;  it  is,  therefore,  very  advisable  for  the 
patient  so  to  live  as,  if  possible,  to  ward  off  this  repetition. 
Generally  he  should  eat  sparingly;  and  fish,  fresh,  well- 
cooked  vegetables,  and  ripe  fruit  should  form  a  considerable 
part  of  his  diet;  he  should  avoid  spirits  and  beer,  and  take 
as  little  stimulant  of  any  kind  as  possible;  strong  coffee  and 
highly  seasoned  dishes  must  be  abstained  from;  he  should 
not  smoke,  or  only  very  moderately  indeed;  he  should  take 
plenty  of  walking  exercise,  but  it  should  not  be  violent  nor 
continued  to  over  fatigue;  he  should  sleep  on  a  mattress  and 
5 


66  INTERNAL    HAEMORRHOIDS. 

never  omit  to  wash  the  affected  part,  night  and  morning, 
with  cold  water;  lastly,  he  should  keep  his  bowels  acting 
daily.  If  this  latter  object  cannot  be  accomplished  without 
some  medicinal  aid,  he  will  find  equal  parts  of  the  con- 
fections of  black  pepper,  sulphur,  and  senna,  a  capital 
remedy  ;  of  this  one  or  two  teaspoonf  uls  may  be  taken  every 
morning  ;  or  night  and  morning,  if  required.  I  have  had 
great  experience  in  the  use  of  the  waters  of  Friedrichshall 
and  Carlsbad  in  these  cases,  and  I  think  them  very  bene- 
ficial, particularly  in  persons  who  are  prone  to  congestion  of 
the  liver.  Another  remedy  I  find  admirable,  /.  e.,  a  tea- 
spoonful  of  the  compound  licorice  powder  of  the  German 
Pharmacopoeia,  taken  in  wineglass  of  water,  twice  or  thrice 
in  the  week  at  bedtime.  A  steady  perseverance  in  the  line 
of  treatment  I  have  suggested  will,  in  all  probability,  eradi- 
cate the  haemorrhoidal  tendency. 


CHAPTER    VIII. 

INTERNAL     HAEMORRHOIDS. 

All  those  causes  I  have  mentioned  as  likely  to  induce 
external  piles  tend  also  to  the  production  of  internal  haemor- 
rhoids, but  in  addition  we  may  name  hereditary  influence, 
diseases  of  the  genito-urinary  system,  and  the  state  of  recov- 
ery from  childbirth. 

During  pregnancy  external  venous  haemorrhoids  are  fre- 
quent, and  these  may,  and  often  do,  pass  away  after  labor, 
in  common  with  varicosities  of  the  legs  and  labia  vaginae  ; 
but  the  reverse  is  the  case  with  regard  to  internal  haemor- 
rhoids; these  most  frequently  make  their  appearance  after 
parturition,  when  all  the  parts  are  relaxed  and  uterine  invo- 
lution is  going  on.  I  will  not  attempt  to  give  any  reason 
for  this  peculiarity;  I  only  state  a  fact  I  have  repeatedly 
observed. 

Our  French  confreres,  for  long  past,  have  not  been  at  all 
satisfied  with  the  usually  accepted  explanation  of  the  eti- 
ology of  piles,  either  external  or  internal.  They  do  not 
consider  that  any  causes  which  are  occasional  can  induce 


INTERNAL    HAEMORRHOIDS.  67 

such  an  afflux  and  stasis  of  blood  in  the  rectal  veins  as  shall 
be  productive  of  haemorrhoids. 

Neither,  say  they,  sedentary  occupation,  excesses  at  the 
table,  venereal .  abuses,  passive  pederasty,  the  immoderate 
and  prolonged  use  of  enemata,  drastic  purgatives,  nor  habitual 
and  severe  constipation,  can,  one  or  all,  initiate  true  haemor- 
hoids.  They,  therefore,  with  praiseworthy  diligence,  sought 
for  the  true  predisposing  cause  in  the  anatomy  and  physiol- 
ogy of  the  rectum;  and  Professor  Verneuil,  the  distinguished 
Parisian  surgeon,  says  he  has  discovered  that  cause  in  the 
peculiar  distribution  of  the  veins  and  the  course  they  take 
in  the  coats  of  the  rectum  a  few  inches  above  the  anus.  The 
preparations  and  dissections  M.  Verneuil  made  to  illustrate 
and  prove  his  views  are  now  in  the  Dupuytren  Miiseum  at 
Paris;  and  the  correctness  of  the  anatomy,  and  the  deduc- 
tions made  from  it,  have,  say  recent  French  authors,  not 
only  been  supported,  but  even  proved,  by  the  dissections  of 
Gosselin  in  1864,  Dubrueil  and  Richard  in  1868,  and  lastly 
by  Duret  in  1877. 

I  shall  endeavor,  as  briefly  and  clearly  as  I  possibly  can, 
to  place  before  my  readers  the  anatomy  as  stated  by  M. 
Verneuil,  because  it  is  considered  to  give  the  reasons  for  a 
method  of  treating  haemorrhoids  strongly  advocated  in 
France,  but,  as  far  as  I  know,  little  practiced  in  England  : — 

I  St.  Professor  Verneuil  considers  that  the  superior  haemor- 
rhoidal  veins  only  are  connected  with  the  portal  system  and 
solely  form  internal  haemorrhoids ;  external  piles  being 
formed  from  the  inferior  and  middle  h^emorrhoidal,  which 
are  connected  with  the  general  venous  system,  and  do  not, 
or  only  in  the  most  remote  degree,  form  connections  with 
the  superior  haemorrhoidal  veins,  and  thus  the  two  venous 
systems,  portal  and  general,  are  practically  distinct. 

2d.  That  the  superior  haemorrhoidal  veins  commence  at 
the  upper  border  of  the  external  sphincter,  and  lie  under 
the  muCous  membrane  of  the  rectum.  At  a  definite  height 
of  about  4  inches  (10  or  11  centimetres)  they  perforate 
abruptly  the  muscular  coats  of  the  bowel,  and  unite  to  form 
the  five  or  six  large  veins  found  in  the  meso-rectum;  these 
then  join  the  inferior  mesenteric  veins,  which  pass  into  the 
splenic  and  portal  veins,  and  thus  enter  the  liver. 

3d.  Where  the  superior  haemorrhoidal  veins  perforate  the 
wall  of  the  rectum,  Verneuil  claims  to  have  discovered  that 
they  pass  through  "veritables  boutonnieres  musculaires," 
which  muscular  button-holes,  not  being  surrounded  by  any 


68  INTERNAL    HAEMORRHOIDS. 

protective  fibroid  tissue,  have  the  power  of  contracting  and 
causing  such  stasis  and  congestion  in  the  superior  hsemor-  , 
rhoidal  veins  as  to  constitute  the  "  primum  mobile  "  in  the 
formation  of  internal  piles.  Dubrueil  further  calls  attention 
to  the  fact  that  the  muscular  button-holes  are  double  and  at 
right  angles  to  each  other,  the  first  set  being  formed  by  the 
circular  fibres,  and  the  second  by  the  longitudinal  fibres  of 
the  rectum.  These  contractile  button-holes  constitute,  says 
Verneuil,  not  only  the  passive,  but  also  the  active  cause  of 
haemorrhoids;  any  intestinal  irritation  will  produce  violent 
and  spasmodic  contractions  of  the  muscular  apertures,  and 
these  contractions  are  communicated  to  the  levator  and 
sphincter  ani  muscles,  and  a  rapid  development  of  internal 
haemorrhoids  will  take  place.  Commonly,  in  addition,  those 
occasional  causes  (formerly  considered  as  primary  causes) 
come  into  play,  and  the  small  varicosities  found  at  the  lower 
border  of  the  internal  sphincter  (and  present  even  in  infants, 
say  the  French)  soon  become  fully  formed  piles.  The  prac- 
tical outcome,  from  the  above  anatomy  and  physiology  by 
the  French  authors,  is  very  important,  viz.,  that  for  the  cure 
of  the  great  majority  of  internal  haemorrhoids,  nothing  is 
required  but  the  gentle  and  thorough  dilatation  of  the  exter- 
nal and  internal  sphincter  muscles;  no  ligature,  no  cautery, 
with  or  w^ithout  clamp,  is  wanted,  and  no  immediate  removal 
of  the  piles  need  take  place.  The  anatomy  of  the  rectum, 
given  by  M.  Verneuil,  has  been  known  for  many  years,  but 
only  recently  (in  1874)  has  the  practice  of  dilatation  been 
recommended  for  the  cure  of  haemorrhoids  by  that  gentle- 
man; and  it  appears  to  me  that  the  discovery  of  that  treat- 
ment was  the  result  rather  of  accident  than  of  reflection  and 
deduction  from  any  known  anatomy  or  physiology.  The 
case  which  opened  the  eyes  of  Professor  Verneuil.  to  the 
advantages  of  dilatation  is  thus  related  by  him  :  "  I  was 
consulted  by  a  distinguished  gentleman  who  had,  for  four- 
teen years,  suffered  from  anal  pains  supposed  to  be  caused 
by  fissure,  but  they  in  reality  were  caused  by  internal  haem- 
orrhoids which  had  become  procidented  and  irreducible  ; 
with  this  state  not  only  had  the  patient's  pains  been  redoub- 
led, but  he  suffered  such  loss  of  blood  as  to  bring  him  near 
to  death;  his  anaemia  was  so  profound  that  I  considered  the 
usual  operative  methods  too  dangerous  to  be  undertaken, 
and  as  the  sphincters  were  very  contracted  I  contented 
myself  by  dilating  them,  and  from  that  day  the  pain  and 
loss  of  blood  ceased,   the  piles   were  cured,  and  did  not 


INTERNAL   HEMORRHOIDS.  69 

return."  "  Encouraged  by  this  happy  experiment,"  says  M. 
Verneuil.  "  I  hastened  to  put  it  into  practice  in  other  cases, 
with  most  excellent  result."  M.  Fontan,  a  little  later,  not 
knowing,  I  presume,  of  M.  Verneuil's  success,  also  acci- 
dentally discovered  that  forcible  dilatation  of  the  sphincters 
cured  haemorrhoids;  for,  says  he,  having  dilated  the  muscles 
for  the  purpose  of  curing  a  fissure  in  a  patient  who  also  suf- 
fered from  hcemorrhoids  (June,  1875),  I  found  that  with  the 
cessation  of  the  symptoms  of  fissure,  the  hemorrhoids,  the 
constipation,  the  daily  bleeding,  and  the  prolapsus  also  dis- 
appeared, and  I  w^as  struck  by  this  unhoped-for  result. 
( Vide  "  Fontan  on  the  Cure  of  Haemorrhoids  by  Forcible 
Dilatation,"  Paris,  1877). 

It  would  be  presumptuous  in  me  to  dispute  the  anatomical 
facts  set  forth  by  Professor  Verneuil,  and  endorsed  by  such 
men  as  Gosselin,  Dubrueil,  Duret,  and  others;  indeed,  the 
dissections  that  I  have  been  able  to  make  induce  me  to  con- 
cur in  the  main  points  set  forth  by  the  learned  professor  ; 
but,  with  all  due  deference,  I  cannot  admit  as  a  fact  the 
almost  absolute  separation  of  the  portal  and  general  venous 
systems.  I  am  quite  confident  that  in  the  dissection  of 
morbid  specimens,  near  the  anus,  you  do  find  a  considerable 
communication  between  the  superior,  inferior,  and  middle 
haemorrhoidal  veins.  One  fallacy,  I  would  suggest,  arises  in 
M.  Verneuil's  physiology,  from  the  fact  of  his  having  injected 
the  superior  haemorrhoidal  veins  from  the  portal  vein,  thus 
forcing  the  injection  from  a  direction  opposed  to  the  natural 
flow  of  the  stream  of  blood.  Again,  admitting  the  existence 
of  the  "button-hole  apertures  through  the  muscular  walls 
of  the  rectum,  I  should  demur  to  the  deduction  made  by 
Mr.  Verneuil,  that  they  cause,  by  contraction,  an  obstacle  to 
the  return  of  blood  from  the  low^er  portion  of  the  rectum  ; 
and,  on  the  contrary,  I  should  infer  that  these  contractile 
apertures  really  play  the  part  of  valves  to  support  the  column 
of  blood  to  the  liver,  and  in  place  of  causing  stasis,  prevent 
it,  by  opposing  regurgitation  in  congested  states  of  that 
organ.  In  the  second  place,  I  would  rather,  in  accordance 
with  general  physiological  principles,  infer  that  the  contrac- 
tion of  the  circular  and  longitudinal  muscular  fibres  of  the 
bowel  favors,  and  does  not  retard,  the  upward  flow  of  the 
blood;  and  I  am  not  convinced,  whatever  may  be  the  value 
of  dilatation  of  the  sphincters  in  treatment,  that  the  physi- 
ology of  M.  Verneuil  explains,  in  a  wholly  satisfactory  man- 
ner, the  causes  and  pathology  of  haemorrhoids.     One  more 


fO  INTERNAL    HEMORRHOIDS. 

point  I  would  mention.  In  Professor  Verneuirs  thesis  he 
makes  no  allusion  to  the  part  played  by  the  arteries  in  the 
formation  of  piles;  yet  I  should  think  no  one  could  fail  to 
note  that  haemorrhoids  are  not  merely  varicosities  of  veins, 
but  tumors,  into  the  structure  of  which  considerable  arteries 
enter.  When,  further  on,  I  discuss  the  various  methods  of 
operating  on  haemorrhoids,  I  shall  give  my  views  and  experi- 
ence of  the  treatment  by  dilatation. 

Internal  piles  present  several  varieties  in  appearance, 
structure,  size,  position,  and  other  characteristics. 

They  may  be  so  small  as  to  exhibit  little  more  than  an 
increased  number  and  size  of  capillary  vessels,  with  thicken- 
ing of  the  submucous  tissue;  in  fact,  there  may  be  only  a 
deep,  red,  velvety  appearance  of  the  mucous  membrane, 
readily  yielding  blood,  or  they  may  be  large,  solid  tumors, 
the  size  of  an  ordinary  bantam  fowl's  egg.  Some  haemor- 
rhoids are  attended  with  bleeding  of  an  arterial  character, 
others  with  venous  haemorrhage,  while  some,  particularly  in 
their  later  stages,  do  not  bleed  at  all.  Some  lie  quietly  high 
up  within  the  internal  sphincter,  and  are  to  be  protruded 
only  by  straining  after  the  administration  of  an  enema ; 
others  always  come  down  at  stool,  and  whenever  the  patient 
makes  any  exertion,  or  stoops,  walks,  or  stands  about  much; 
again,  some  are  always  down.  This  last  symptom  is  pecu- 
liar to  old-standing  cases.  These  various  conditions  depend, 
in  great  measure,  upon  the  duration  of  the  disease  and  the 
condition  of  the  sphincter  muscles  as  to  strength  or  weak- 
ness ;  a  relaxed  condition,  such  as  frequently  exists  in 
women,  and  in  men  of  lax  fibre,  allowing  the  protrusion  of 
even  small  haemorrhoids  on  the  slightest  exertion.  This  may 
be  specially  noticed  in  the  common  case  of  a  perineal  haem- 
orrhoid  in  females  who  have  borne  children. 

As  a  rule,  patients  do  not  suffer  much  from  internal  hem- 
orrhoids, unless  they  become  inflamed,  or  are  constantly 
coming  down  and  getting  compressed  by  the  sphincters; 
hence,  the  amount  of  suffering  depends,  in  a  measure,  upon 
the  state  of  these  muscles,  as  does  also  the  amount  of  con- 
gestion of  the  piles  themselves.  Inflammation  is  very  soon 
lighted  up  in  these  cases;  unusual  straining,  with  a  costive 
motion,  a  drastic  purge,  sitting  on  a  damp  seat,  excessive 
sexual  indulgence,  or  a  little  excess  in  alcohol,  or  in  eating, 
may  be  sufficient  to  start  it.  When  the  part  is  extruded, 
and  gets  nipped  by  the  sphincters,  partial  strangulation 
takes  place,  and  in  some  cases  you  see  large,  inflamed,  bluish 


INTERNAL   HiEMORRHOlBS.  7I 

haemorrhoids  constricted,  by  a  broad  band  of  everted  sphinc- 
ter muscle  and  mucous  membrane,  and  this  constriction 
may  take  place  to  such  an  extent  as  to  occasion  more  or  less 
sphacelus.  I  have  very  rarely  seen  this  occur  to  a  degree 
sufficient  to  effect  a  cure  of  the  malady,  although  it  may 
afford,  temporarily,  great  relief. 

In  the  earlier  stages  of  the  complaint,  when  the  piles  come 
down  at  stool,  they  nearly  always  bleed,  but  they  spontane- 
ously return  within  the  sphincter  after  the  bowel  is  emptied, 
or  upon  the  patient  resuming  the  erect  posture,  or,  at  all 
events,  upon  lying  down  and  voluntarily  retracting  them; 
and  then  the  bleeding  ceases.  Later  in  the  progress  of  the 
disease,  the  patient  is  compelled  to  return  them  by  pressure, 
and  then  they  keep  up;  but,  in  still  further  advanced  cases, 
although  returned,  they  will  not  remain  in  place  if  the  least 
exertion  be  made. 

As  regards  the  structure  and  appearance  of  internal  haem- 
orrhoids, three  broadly  marked  kinds  may  be  observed,  viz.: 
the  capillary  haemorrhoid,  the  arterial  hsemorrhoid,  and  the 
venous  haemorrhoid;  at  times  all  perfectly  distinct,  at  others, 
united  in  the  same  patient. 

I'he  first  variety  I  should  describe  as  small,  florid,  rasp- 
berry-looking tumors,  having  a  granular,  spongy  surface,  and 
bleeding  on  the  slightest  touch ;  these  piles  are  often  situa- 
ted rather  high  in  the  bowel.  Although  they  are  so  insig- 
nificant in  size,  the  quantity  of  blood  lost  from  them  may  be 
very  considerable,  and  occasion  a  serious  drain  upon  the 
patient's  constitution;  I  have  seen  many  persons  quite 
blanched  by  the  losses  they  sustain. 

In  structure  they  consist  almost  entirely  of  hypertrophic 
capillary  vessels  and  spongy  connective  tissue,  and,  there- 
fore, I  tnink  a  good  name  for  them  is  the  "  capillary  haem- 
orrhoid." They  resemble  arterial  naevi  very  closely,  indeed, 
in  their  microscopic  structure,  except  that  they  are  covered, 
externally,  by  a  very  much  thinner  membrane,  and,  conse- 
quently, are  readily  made  to  bleed.  If  these  haemorrhoids 
exist  for  a  considerable  time  uninterfered  with,  or  if  power- 
ful astringents  are  applied  to  them,  they  lose  their  velvety, 
granular  appearance,  the  bleeding  ceases  or  diminishes 
greatly,  and  they  remain  dormant  for  a  longer  or  shorter 
period;  but,  in  most  cases,  they  eventually  recommence 
growing,  and  assume  a  smooth,  shining  surface,  resembling 
ordinary  mucous  membrane;  at  the  same  time,  the  main  ves- 
sels feeding  the  growth  increase  in  diameter,  and  the  areolar 


72  INTERNAL   HAEMORRHOIDS. 

tissue  becomes  thickened  and  more  abundant;  an  exuda- 
tion of  lymph  and  fibrinous  matter  takes  place  beneath  the 
mucous  membrane,  obliterating  the  capillaries  and  arresting 
the  bleeding  from  the  surface.  These  changes  I  believe  to 
be  the  result  of  slow  processes  of  inflammation.  I  am  here 
only  describing  what  I  have  repeatedly  seen,  and  I  think  in 
this  way  most  commonly  the  second  variety,  or  arterial 
internal  haemorrhoid,  is  formed. 

They  may  be  thus  described:  Tumors  varying  in  size, 
attaining  sometimes  very  considerable  dimensions,  glistening 
on  their  surface,  slippery  to  the  touch,  hard  and  vascular;  if 
scratched  they  bleed  freely;  the  blood  is  bright  red  and 
issues  "per  saltum."  If  you  pass  your  finger  into  the  bowel 
you  will  feel  entering  into  the  upper  part  of  each  hemorrhoid 
an  artery,  pulsating  with  as  much  force  as  the  radial,  and,  in 
many  cases,  of  a  calibre  but  little  less  than  it.  On  dissecting 
one  of  these  tumors  you  will  find  it  consists  of  numerous 
arteries  and  veins  freely  anastomosing,  tortuous,  and  some- 
times dilated  into  pouches,  and  a  stroma  of  cell  growth  and 
connective  tissue,  the  latter  most  abounding.  These  advan- 
ced haemorrhoids  are  ceatainly  not,  as  some  have  described 
them,  merely  dilated  vessels  with  a  little  cellular  tissue,  or 
sacs,  or  cells  with  fluid  contents  which  can  be  emptied  by 
squeezing. 

The  third  variety  of  the  venous  internal  haemorrhoid,  and 
in  this  the  venous  system  predominates.  The  tumors  are 
often  very  large.  I  have  seen  them  quite  the  size  of  a  hen's 
egg.  They  are  bluish  or  livid  in  color,  and  they  are  hardish; 
the  surface  may  be  smooth  and  shiny  or  pseudo-cutaneous; 
they  prolapse  very  readily,  and  are  often  constantly  down; 
they  do  not  usually  bleed  much,  but  if  pricked  the  blood 
may  be  either  venous  or  arterial.  This  form  is  commonly 
found  in  women  who  have  borne  many  children  and  who  have 
an  enlarged  or  retroverted  uterus;  they  often  occur  about  the 
change  of  life.  This  form  of  haemorrhoid  may  be  called 
"  the  passive  kind."  They  are  also  seen  in  men  with 
enlarged  or  indurated  livers,  in  whom  the  portal  system  is 
constantly  engorged,  and  the  circulation  through  the  abdom- 
inal viscera  is  obstructed.  This  is  the  form  of  haemorrhoid 
spirit-drinkers  get.* 

*Although  venous  haemorrhoids  are  usually  found  in  adults,  I  have  seen 
them  in  children  Here  is  a  case.  Henry  S — ,  aged  3,  was  brought  to 
St.  Mark's  Hospital,  October,  1865.  He  never  was  a  robust  child,  and 
looks  delicate  now.     For  eighteen  months  his  mother  had  noticed  some- 


INTERNAL   HAEMORRHOIDS.  73 

I  never  hesitate  to  operate  on  these  cases,  but  I  observe 
certain  precautions  before  doing  so;  if  the  liver  is  in  fault  I 
prescribe  careful  living,  a  course  of  Carlsbad  waters,  and  the 
"  wet  pad  "  over  the  liver,  together  with  shampooing  and  the 
cold  douche;  also  the  chloride  of  ammonium  may  be  very 
useful  (3  or  4  grains  three  times  in  the  day).  In  women  any 
uterine  complication  should  be  attended  to;  and  in  men  after 
the  operation  it  will  not  do  to  allow  them  to  live  freely;  for 
some  little  time  the  bowels  should  be  kept  acting  well,  and 
stimulants  should  be  interdicted;  if  these  precautions  be 
neglected  you.may  get  symptoms  of  congestion  of  the  head, 
shown  by  flushed  face  and  tensive,  throbbing  headache,  or 
an  attack  of  gout  may  supervene,  as  I  have  seen  on  several 
occasions.  Sometsmes  haemorrhage  of  venous  character 
will  take  place  a  week  or  ten  days  after  the  operation,  from 
the  surface  of  the  unliealed  wounds;  if  this  is  not  excessive 
it  should  not  be  interfered  with.  No  doubt  there  are  the 
cases  that  the  old  writers  advised  should  not  be  operated 
upon,  for  fear  of  apoplexy  or  other  internal  disease  result- 
ing. My  experience  is  that  there  is  no  danger  if  ordinary 
common-sense  precautions  are  adopted. 

I  have  frequently  been  consulted  as  to  the  propriety  of 
operating  upon  haemorrhoids  in  pregnant  women.  I  think 
the  operation  quite  admissible  if  the  patient  is  losing  much 
blood  or  suffering  greatly.  I  recently  had  a  case  at  St. 
Mark's,  in  a  woman,  five  months  pregnant,  who  was  voiding 
such  quantities  of  blood  that  she  was  quite  blanched,  and  it 
was  absolutely  necessary  to  interfere;  she  had  no  untoward 
symptoms  after  the  ligature  of  five  piles,  nor  was  her  recov- 
ery much  retarded.  I  have  operated  many  times,  always  in 
urgent  cases,  but  only  once  has  a  miscarriage  resulted.  I 
always  keep  the  patient  recumbent  longer  than  ordinary 
cases,  as,  if  they  get  about  too  soon  the  wounds  do  not  heal 
well. 

It  has  often  occurred  to  me  to  point  out  the  three  varieties 
of  haemorrhoids  I  have   described,  as  existing  at    the   same 

thing  come  down  when  he  went  to  stool;  latterly  he  complained  of  pain, 
and  There  had  been  slight  bleeding.  On  examination  nothing  abnormal 
could  be  seen.  Of  course  I  suspected  polypus  and  ordered  an  injection 
to  be  given;  after  the  bowels  had  acted  I  found  three  well-marked  venous 
haemorrhoids  had  come  down  outside.  There  was  slight  ulceration  of 
the  mucous  membranes  between  them.  Laxatives,  cod-liver  oil  and 
steel  wine,  together  with  the  use  of  astringent  ointments,  effected  a 
cure. 


74  INTERNAL    HEMORRHOIDS. 

time  in  the  same  patient,  a  circumstance  which,  I  think, 
tends  to  confirm  the  opinion  I  entertain  that  they  are  only 
modifications  of  one  initial  disorder.  I  would  by  no  means 
dogmatically  affirm  that  what  I  have  called  the  "  arterial 
hgemorrhoid"  always  follows,  or  is  preceded  by  the  capillary 
form  of  haemorrhoid,  but  I  am  sure  it  is  frequently  so;  it  has 
happened  to  me  several  times  to  see  cases  where  nitric  acid 
has  been  applied  to  capillary  piles  with  the  result  of  arresting 
the  bleeding,  and  for  months  or  longer  relieving  the  patient, 
but  the  second  variety  of  haemorrhoid  has  been  gradually 
growing,  and  fully  formed  tumors  have  eventually  become 
developed. 

Here  is  an  illustration. 

A  gentleman  came  under  my  care  in  the  year  1862.  He 
had  two  very  characteristic  capillary  haemorrhoids,  and  lost 
almost  daily  a  quantity  of  blood.  The  case  was  one  pecu- 
liarly well  suited  for  the  nitric  acid  treatment,  which  at  that 
time  was  much  practiced.  I  applied  the  acid  thoroughly 
without  causing  any  severe  pain.  The  result  was  highly  sat- 
isfactory, the  bleeding  was  at  once  stopped,  and  the  patient 
left  my  care  quite  happy. 

In  the  year  1864,  about  eighteen  months  after  I  had  first 
seen  him,  he  again  consulted  me,  complaining  of  discomfort 
in  the  rectum  and  of  a  protrusion  on  going  to  stool.  He 
only  very  occasionally  lost  blood;  on  examination  after  an 
injection  I  found  three  haemorrhoids  fully  formed,  and  I 
advised  an  operation  by  ligature.  He,  however,  objected  to 
that,  and  wished  me  to  re-apply  the  acid;  this  I  declined  to 
do,  knowing  that  it  would  not  in  any  degree  benefit  him. 
He  went  away  to  consider  whether  he  would  have  the  oper- 
ation done,  but  he  did  not  return  again  for  nine  or  ten 
months;  he  then  told  me  that  after  seeing  me  he  consulted 
another  surgeon,  who  applied  nitric  acid  four  times  for  him, 
but  that  he  had  gained  only  very  temporary  benefit,  and 
that  he  was  now  worse  than  ever  and  wished  for  a  radical 
cure.  On  examining  him  I  found  five  haemorrhoids,  three 
large  and  of  the  venous  character,  and  two  small,  of  the 
capillary  kind,  which  had  formed  since  I  saw  him. 

Some  years  ago  it  was  a  common  thing  for  patients 
to  come  to  St,  Mark's  Hospital  with  advanced  haemor- 
rhoids, relating  this  history:  "  Their  piles  had  been  (as 
they  called  it)  operated  on  a  year  or  so  before,  with  acid, 
and  for  some  time  they  were  better,  but  that  latterly  they 
had  become  worse  than  ever,  but  they  rarely  bleed   now, 


INTERNAL    HAEMORRHOIDS.  75 

although  before  the  acid  was  applied  they  lost  a  good 
deal." 

Although  the  three  broad  divisions  I  have  described  are 
most  usually  seen,  sometimes  it  occurs  to  one  to  find  a  large 
haemorrhoidal  tumor  with  a  granular  capillary  surface  which 
bleeds  very  freely;  these  are  piles  that,  for  some  reason  or 
other,  have  formed  and  grown  very  rapidly;  they  are  usually 
situated  high  up  the  bowel,  and  have  not  protruded,  and 
have  not  suffered  from  repeated  attacks  of  inflammation. 

In  the  velvety  or  capillary  haemorrhoid  the  patient's  symp- 
toms are  principally  such  as  arise  from  repeated  small  losses 
of  arterial  blood,  which  I  have  noticed  are  much  more 
exhausting  than  venous  haemorrhages;  the  latter  often  relieve, 
the  former  always,  in  time,  depress.  These  piles  are  so 
small  that  they  give  no  trouble  by  their  size,  and  they  pro- 
trude only  slightly,  if  at  all,  on  going  to  the  closet;  more- 
over, there  is  no  pain  unless  there  be  the  complication  of 
ulceration.  These  patients  complain  of  frequent  pains  in 
the  back  and  loins,  also,  in  the  male,  in  the  spermatic  cord 
and  testicles;  they  have  great  lassitude,  and  not  unfre- 
quently  the  sexual  powers  are  interfered  with.  I  have  seen 
many  cases  in  which  this  was  the  symptom  that  induced  the 
person  to  seek  advice.  One  case  particularly  is  recalled  to 
my  mind,  from  the  fact  that  the  gentleman  had  paid  a  large 
sum  of  money  to  a  charlatan  who  had  been  treating  him  for 
impotence,  the  result  of  spermatorrhoea.  In  women  men- 
struation may  gradually  cease,  and  a  condition  of  profound 
anaemia  result.  This  is  well  illustrated  by  a  case  that  was 
sent  me  by  my  friend,  the  late  Dr.  Chapman,  of  Biarritz. 

A  young  lady,  set.  20,  formerly  robust  and  healthy,  grad- 
ually fell  ill;  she  became  languid,  fretful,  fanciful,  and  very 
anaemic.  Menstruation  ceased  almost  entirely;  only  once 
in  three  or  four  months  had  she  a  scanty,  pale  discharge. 
She  did  not  complain  of  any  pain  except  in  the  back  and 
legs  on  attempting  to  walk.  She  had  taken  any  quantity  of 
ferruginous  medicines,  and  had  been  recommended  by 
various  medical  men  to  try  the  baths  at  Schwalbach  and 
and  other  German  watering-places,  the  disorder  being  sup- 
posed to  be  uterine.  Through  delicacy  she  never  mentioned 
that  she  had  lost  blood  per  anmn^  and  she  had  never  been 
directly  asked  the  question.  Fortunately  for  her.  Dr.  Chap- 
man, under  whose  care  she  came,  put  it  to  her  point  blank, 
when  she  admitted  that  she  bled  almost  daily  when  the 
bowels  acted.     The  mystery  was  now  solved.     By  the  advice 


76  INTERNAL    HEMORRHOIDS. 

of  Dr.  Chapman  she  came  to  me,  and  I  found  that  she  had 
three  very  vascular  capillary  haemorrhoids.  I  removed  them; 
recovery  ensued  without  a  bad  symptom,  and  she  soon 
regained  her  former  health. 

I  was  consulted  two  years  ago  by  a  physician,  about  his 
daughter,  who  had  fallen  into  a  very  despondent  state  of 
mind,  and  was  also  weak  and  anaemic.  Menstruation  had 
ceased  for  some  months.  Uterine  disease  had  been  diag- 
nosed and  treated  without  benefit.  Latterly  she  said  some- 
thing was  the  matter  with  her  bowel,  and  advice  was  sought. 
On  interrogation  it  appeared  that  she  lost  blood  almost 
daily,  and  occasionally  in  large  quantities,  so  that  she  had 
fainted  in  the  water-closet.  Nothing  protruded,  and  she 
had  no  actual  pain,  only  a  burning  sensation  at  the  bottom 
of  the  back. 

On  examination  I  found  an  extremely  vascular  patch  of 
mucous  membrane  over  the  internal  sphincter,  about  the 
size  of  a  shilling.  It  yielded  arterial  blood  at  the  slightest 
toifch,  and  the  sphincter  muscles  were  somewhat  contracted. 
Gentle  dilatation  and  one  touch  with  the  Paquelin  cautery 
completely  cured  her. 

It  is  these  daily  small  losses  which  are  apt  to  be  over- 
looked, and  which  female  patients  accustomed  to  their 
monthly  flux  scarcely  think  worthy  of  mention,  but  which, 
when  added  to  menstruation,  become  a  serious  matter,  and 
speedily  induce  chlorosis  and  an  amount  of  debility  which 
can  be  combated  only  by  removing  the  primary  cause  of  the 
malady.  Very  tiresome  constipation  is  usually  found  attend- 
ant upon  this  condition,  and  often  continues  after  the 
patient  has  recovered  her  general  health.  It  is  only  to  be 
overcome  by  patient  attention  to  diet,  exercise,  and  the 
administration  of  such  medicines  as  give  tone  and  gently 
stimulate  the  colon,  without  irritating  or  purging.  I  have 
found  faradization  a  valuable  adjunct  to  other  treatment. 
You  do  not  generally  find  more  than  two  or  three  capillary 
haemorrhoids  in  the  same  .patient — very  often  only  one,  and 
in  women  this  is  almost  always  situated  anteriorly,  and  then 
it  is  very  easily  prolapsed.  It  is  this  variety  of  the  disease 
which  is  benefited  by  the  application  of  fuming  nitric  acid 
— I  say  benefited,  not  absolutely  cured,  for,  in  my  expe- 
rience, you  cannot  by  any  means  be  certain  of  effecting  the 
latter  result.  Had  the  use  of  the  acid  been  restricted  to 
this  form  of  pile,  it  would  not  have  fallen  into  such  utter 
disuse  as  it  has;  it  was  the  unsurgical  attempt  to  cure  large, 


INTERNAL   HEMORRHOIDS.  77 

hard  haemorrhoids  with  it  that  brought  it  into  discredit.  In 
these  small,  vascular,  granular  piles,  strong  carbolic  acid  is 
a  very  good  application,  as  also  is  the  subsulphate  of  iron  in 
the  form  of  an  ointment  (  3  ss  to  3  j  of  Unguentum  Cetacei 
is  the  strength  I  employ)  or  as  a  suppository  (gr.  ij  c.  gr.  v 
Cacao  butter).  It  acts  as  a  most  powerful  astringent;  it  is 
not  cauterant;  it  causes  no  pain;  in  fact,  in  inflamed  hemor- 
rhoids it  seems  to  act  as  a  sedative;  it  arrests  haemorrhage 
with  absolute  certainty.  I  have  with  this  remedy  effected 
many  cures,  and  materially  relieved  numbers  of  cases  when 
an  operation  has  not  been  desirable,  or  when  the  patient 
was  too  nervous  to  submit  to  one.  I  am  confident  now, 
from  a  large  experience,  that  it  is  a  most  valuable  agent  in 
the  treatment  of  many  rectal  affections.  Rouse  &  Co.,  the 
chemists  in  Wigmore  Street,  prepared  for  me  an  excellent 
Liquor  Ferri  Subsulphatis,  and  I  found  it  answer  admirably 
as  a  styptic  and  astringent  in  small  ulcerations  as  well  as 
capillary  haemorrhoids. 

I  may  as  well  remark  here  that  the  capillary  haemorrhoid, 
or  the  pile  with  a  capillary  surface,  is  the  only  form  likely 
to  be  benefited  by  the  application  of  nitric  acid  or  acid 
nitrate  of  mercury.  Ten  years  ago,  when  this  treatment 
was  in  vogue,  it  was  frequently  used  in  the  most  reckless 
and  unscientific  manner,  quite  regardless  of  how  much  it 
really  could  do.  I  used  to  see  at  the  hospital  patients  with 
large,  fully  developed  rectal  tumors,  to  which  acid  had  been 
applied  half  a  dozen  or  more  times,  causing  great  pain, 
and  with  the  result  of  no  real  curative  impression  being 
made  upon  the  disease.  I  am  sorry  to  say  this  method  is 
not  yet  quite  obsolete,  for  not  very  long  ago  I  saw,  with  Dr. 
Playfair,  an  elderly  lady  with  large  piles,  who  had  suffered 
very  severely  from  several  applications  of  strong  acid,  made 
a  short  time  before  by  a  hospital  surgeon  of  considerable 
repute. 

In  the  second  variety,  or  arterial  internal  haemorrhoid,  the 
suffering  occasioned  is  more  directly  associated  with  the  con- 
dition of  the  haemorrhoid  itself  as  to  the  inflammation  and 
ulceration,  and  with  the  state  of  the  sphincter  ani  muscles. 
These  piles  protrude  at  stool,  or  on  making  some  particular 
movements,  as  stooping,  etc.,  and  in  that  way  alone  they 
cause  much  discomfort;  they  also  discharge  a  gummy,  acrid 
mucus,  which  keeps  the  part  constantly  damp,  leads  to  excori- 
ations around  the  anus,  and  favors  the  growth  of  cutaneous 
excrescences;  moreover,    it    stains    the  linen,   and    on  this 


78  INTERNAL    HAEMORRHOIDS. 

account  is  a  source  of  great  annoyance  to  sensitive,  delicate- 
minded  persons.  Generally,  after  visiting  the  water-closet, 
the  patient  is  some  time  before  he  can  get  at  all  comforta- 
ble, often  having  to  lie  down,  and  when  he  walks  about  he 
is  almost  always  aware  of  the  fact  that  he  has  a  rectum.  In 
health,  no  person  feels  that  he  possesses  one  organ  more 
than  another,  unless  he  has  to  use  that  organ;  after  the  first 
intimation  of  impairment  of  health  is  the  recognition  of  the 
fact  that  there  is  a  preponderance  of  sensitiveness  or  some 
abnormal  sensation  in  one  member  of  the  body.  So,  in  rec- 
tal diseases  the  fact  is  always  present  to  the  mind  of  the 
sufferer  that  he  has  an  anus.  He  scarcely  ever  feels  that 
his  bowel  has  been  properly  relieved,  and  this  feeling  often 
leads  to  frequent  visits  to  the  closet,  and  attempts  to  procure 
satisfaction  by  straining,  which  ultimately  aggravates  the 
malady.  The  condition  of  the  sphincter  ani  plays  an 
important  part  in  causing  distress;  if  it  be  strong  and  tight, 
when  the  piles  come  down,  they  get  nipped,  and  their  return 
is  rendered  difficult  and  painful;  on  the  other  hand,  if  the 
sphincter  be  lax,  the  bowel  is  constantly  coming  outside  on 
the  slightest  exertion,  as  in  coughing,  stooping,  or  even  walk- 
ing; and  in  these  cases,  when  the  bowel  is  down,  the  patient 
can  seldem  retain  liquid  motions.  I  frequently  meet  with 
patients  who  say  they  have  to  retire  to  a  urinal  and  push  up 
the  protrusion  when  it  descends,  or  they  cannot  walk  at  all. 
The  employment,  of  course,  has  much  to  do  with  the  dis- 
comfort of  the  patient;  again,  constipation  adds  greatly  to 
the  severity  of  the  symptoms,  and  so  also  does  habitual 
relaxation,  which,  by  causing  frequent  protrusion,  induces 
inflammation  and  ulceration  of  the  part.  These  advanced 
haemorrhoids  are  almost  always  associated  with  cutaneous 
hypertrophies  around  the  anus,  and  these,  being  irritated  by 
the  discharges,  become  inflamed  and  very  tender.  Some- 
times I  have  seen  a  number  of  polypoid  growths  studded 
over  the  mucous  membrane  at  the  entrance  to  the  anus;  in 
a  patient  of  mine,  at  St.  Mark's  Hospital,  I  counted  twelve 
of  these,  and  recently  I  have  had  a  private  patient  on  whom 
I  counted  twenty-two  excrescences. 

When  called  to  a  patient  who  has  forced  his  piles  down 
and  cannot  return  them,  proceed  in  this  way:  Place  him  flat 
on  his  face,  with  three  or  four  pillows  under  his  pelvis,  to 
raise  the  hips  well  up  and  allow  the  intestines  to  gravitate 
toward  the  chest;  then  smear  the  piles  over  with  some  oint- 
ment, pass  one  finger  into  the  bowel,  and  with  the  other  hand 


INTERNAL    HAEMORRHOIDS.  79 

gently  apply  pressure,  trying  to  empty  the  piles  of  their 
superfluous  quantity  of  blood;  this  should  be  done  very 
gently,  as  you  would  apply  taxis  to  a  hernia.  Should  this 
not  succeed,  place  a  bladder  of  ice  over  the  part,  and  leave 
the  patient  in  the  position  I  have  recommended  for  an  hour; 
then  try  taxis  again,  and  you  will  in  all  probability  return 
the  mass.  I  have  found,  on  several  occasions,  that  freezing 
with  the  ether  spray  has  been  an  effective  and  more  rapid 
method  of  inducing  contraction  temporarily,  and  removing 
the  sensitiveness,  so  that  you  can  apply  more  direct  pressure, 
but  I  am  bound  to  say  this  manoeuvre  is  usually  followed  by 
severe  burning  pain  in  the  rectum.  If  your  attempts  at 
replacing  the  piles  have  not  been  successful,  try  to  persuade 
the  patient  to  have  them  operated  upon  without  delay;  if 
he  will  not  accede  to  this  proposal,  you  may  order  some 
leeches,  or  apply  moderate  cold.  If  there  be  much  stran- 
gulation, ice  should  not  be  kept  on  very  long,  or  you  may 
produce  more  sphacelus  than  you  desire.  In  some  instances 
warm  applications,  with  sedatives,  are  more  comforting,  and 
relieve  pain  sooner  than  cold.  • 

For  my  own  part  I  never  hesitate  to  operate  at  once  if  I 
can  get  my  patient's  consent;  a  speedy  and  radical  cure  of 
the  disease  is  thus  obtained.  I  never  saw  a  case  of  this  kind 
do  badly,  although  some  surgeons  have  said  that  inflamed 
haemorrhoids  should  not  be  operated  upon.  I  will  make  an 
exception  in  cases  of  protruded  piles,  where  mortification 
has  set  in  to  any  extent;  here,  although  it  may  be  necessary 
to  operate,  care  must  be  taken,  as  the  tissues  are  so  broken 
down  that  the  ligatures  will  not  hold,  and  haemorrhage  may 
result.  In  a  case  I  had,  in  the  practice  of  Dr.  Tanner,  of 
Newington,  the  parts  were  so  friable  that  the  ligatures  cut 
through  the  piles,  and  there  was  considerable  difficulty  in 
arresting  the  bleeding;  I  accomplished  it  by  passing  a  tena- 
culum deeply  below  the  vessels,  and  applying  a  ligature 
around  it.  I  then  cut  the  tenaculum  away  from  the  handle, 
and  left  it  ;n  for  three  days.  This  patient  did  exceedingly 
well,  and  was  about  in  less  than  a  fortnight. 

In  old-standing  prolapsed  haemorrhoids  there  is  frequently 
a  difficulty  in  retaining  wind  or  loose  motion;  this  is  caused, 
in  part,  by  the  relaxed,*  weak  state  of  the  sphincter,  but  more 
particularly,  I  believe,  by  the  loss  of  the  acute  sensitiveness 
of  the  mucous  membrane  at  the  lower  part  of  the  rectum. 
This  sensibility  in  the  healthy  subject  gives  timely  warning 
to  the  sphincter  ani  to  contract  when  necessary. 


8o  INTERNAL    HAEMORRHOIDS. 

Very  rarely,  in  advanced  states  of  haemorrhoidal  disease, 
is  a  cure  effected  without  having  recourse  to  an  operation, 
but  I  have  seen  such  cases;  one  particularly  recurs  to  my 
mind,  from  the  fact  that  1  had  given  a  most  positive  opinion 
that  no  permanent  benefit  could  be  obtained  without  oper- 
ating. This  was  a  gentleman,  past  middle  age,  who  had  suf- 
fered for  years;  his  piles  were  full  sized,  they  used  to  bleed 
much,  and  always  protruded  more  or  less  at  stool;  they  were 
of  the  venous  passive  form,  and  no  doubt  were  dependent  in 
some  degree  on  the  condition  of  the  liver.  In  this  case, 
great  attention  to  the  state  of  the  bowels,  the  patient  always 
lying  down  to  have  an  action,  and  remaining  recumbent  for 
an  hour  or  two  afterwards;  care  as  to  diet,  which  was  of  the 
most  unstimulating  character,  and  almost  devoid  of  alcohol; 
smearing  the  piles  over  with  the  subsulphate  of  iron  and 
other  astringent  ointments;  the  occasional  use  of  a  full-sized 
bougie;  injection  of  a  quarter  of  a  pint  of  cold  water  daily, 
and  the  internal  administration  of  Ward's  paste,  tincture  of 
the  muriate  of  iron,  and  other  remedies,  in  about  four  years 
effected  a  cure.  At  least,  he  told  me  lately  that  he  had  no 
trouble  now  with  his  piles;  nothing  came  down  at  stool,  he 
had  no  bleeding,  and  suffered  no  other  inconvenience.  This 
gentleman  was,  I  must  say,  able  to  command  every  comfort, 
and  was  never  in  anyway  compelled  to  exert  himself;  he  had 
an  insuperable  objection  to  anything  like  an  operation,  but  was 
most  determined,  persevering,  painstaking,  and  intelligent  in 
carrying  out  all  the  devices  I  have  mentioned.  Such  condi- 
tions are  rarely  met  with  in  ordinary  life;  and  therefore,  for 
all  practical  purposes,  it  may  be  said  an  operation  is  indis- 
pensable. I  have,  since  this  case,  met  with  others  of  a  simi- 
lar character,  and  some  have  yielded  to  general  treatment 
and  the  internal  use  of  the  chloride  of  ammonium. 

It  is  in  this,  the  third  or  venous  kind  of  pile,  that  I  think 
constitutional  treatment  most  likely  to  be  successful,  not, 
perhaps,  in  always  curing  the  disease,  but  in  materially  alle- 
viating it,  as  the  malady  often  depends  upon  uterine  or  liver 
affections,and  a  generally  overloaded,congested  condition  of 
the  system  found  in  those  who  habitually  eat  and  drink  too 
much,  and  who  take  but  little  exercise;  these  causes  may, 
to  a  great  extent,  if  not  altogether,  be  removed,  and  if  they 
are  so,  the  haemorrhoidal  disorder  will  be  found  to  be  bene- 
fited to  an  equal  degree.  A  prolonged  course  of  the  Fried- 
richshall  and  Carlsbad  waters  will  be  found  useful.  I  have 
also  seen  benefit  derived  from  the  oil  of  sandal  wool   taken 


INTERNAL    HEMORRHOIDS.  8l 

in  conjunction  with  such  remedies  as  relieve  congestion  of 
the  portal  system,  and  depurate  the  blood  generally. 

Professor  Richet,  of  Paris,  at  Hotel  Dieu,  delivered  a  lec- 
ture on  what  he  termed  "  white  piles  "  {Jiemorrhoide  blanche) 
as  they  did  not  discharge  blood,  like  ordinary  internal 
hemorrhoids,  but  a  sero-mucous  fluid.  The  professor  stated 
that  the  white  piles  are  merely  ordinary  piles  in  a  more 
advanced  stage,  and  consisted  principally  of  hypertrophy  of 
the  papillary  bodies  of  the  mucous  membrane.  The  inces- 
sant discharge  acted  as  perniciously  as  frequent  bleeding, 
being  nothing  more  or  less  than  transformed  blood;  and  he 
advised  them  to  be  operated  on  in  the  usual  way,  preferring 
himself  the  cautery  to  any  other  method;  he  objected  to  Chas- 
saignac's  "ecraseur,"  or  Maisonneuve's  wire  "constricteur," 
which,  he  says,  often  produce  permanent  contraction  of  the 
anus.  For  my  part,  while  agreeing  with  M.  Richet,  I  do 
not  see  any  sufficient  reason  for  introducing  a  new  name  in 
addition  to  those  generally  in  use. 

In  women  suffering  from  a  retroverted  or  anteverted 
uterus  an  operation  upon  piles  is  very  undesirable,  and  will 
most  certainly  end  in  disappointment  unless  the  uterine 
complication  he  attended  to  at  the  same  time,  or  what  is  bet- 
ter, prior,  to  the  operation.  My  experience  warrants  me  in 
saying  that  the  rectal  affection  will  soon  become  a  compara- 
tively small  matter.  In  my  early  operation  upon  women  I 
did  not  take  into  sufficient  consideration  the  condition  of  the 
uterus,  and  I  could  relate  many  cases  in  which  I  was  most 
griew)usly  annoyed  to  find  that  the  patient  did  not  recover, 
as  I  anticipated  she  would  have  done.  I  have  found  that 
if  the  wounds  heal  there  is  but  little  relief  afforded  ;  the 
same  bearing  down  and  distressing  sensation  exists  in  the 
bowel  as  it  did  before  the  removal  of  the  piles.  More  com- 
monly the  wounds  do  not  heal,  and  very  painful,  unhealthy 
ulceration  follows;  this  will  never  get  well  as  long  as  the 
abnormal  condition  of  the  uterus  remains,  I  will  briefly 
related  a  case  or  two  bearing  upon  this  point. 

Mary  C — ,  set.  34,  came  under  my  care,  in  the  early  part 
of  the  year  1842,  at  the  Farringdon  Dispensary.  She  was  a 
single  woman,  and  had  suffered  for  years  from  haemorrhoids; 
they  came  down  at  stool;  she  lost  blood  and  had  much  bear- 
ing down;  she  was  likewise  troubled  with  her  water,  passed 
it  very  frequently,  and  with  difficulty,  never  feeling  that  she 
had  quite  emptied  the  bladder.  The  urine  was  not  turbid, 
and  she  did  not  have  actual  pain — only  discomfort.  On 
6 


82  INTERNAL    HEMORRHOIDS. 

examination  four  full-sized  haemorrhoids  were  found  (their 
character  is  not  stated  in  my  note  book).  Aided  by  my 
friends,  Dr.  Frodsham  and  Mr.  Charles  Smith,  I  applied 
ligatures  to  them.  The  operation  was  followed  by  retention 
of  urine,  and  a  catheter  had  to  be  passed  for  the  first  few 
days.  While  she  was  in  bed  she  seemed  better,  but  after  a 
fortnight,  when  she  began  to  get  about,  she  complained  of 
bearing  down  in  the  "  back-passage,"  and  much  pain  in  defe- 
cation. The  bowels  were  very  difficult  to  get  to  act.  These 
symptoms  I  had  expected  would  pass  away  when  the  wounds 
were  quite  healed;  but,  to  my  dismay,  they  did  not,  and  two 
months  after  the  operation  1  found  there  was  ulceration  of 
the  bowel,  and  she  suffered  a  great  deal.  I  had  for  some 
time  suspected  that  the  uterus  was  not  right,  so  I  obtained 
the  opinion  of  Dr.  Edward  Cock,  who  was  at  that  time  obs- 
tetric physician  to  the  Dispensary,  and  that  gentleman  pro- 
nounced thas  she  had  a  fibroid  tumor  of  the  uterus  (this 
diagnosis  was  afterwards  confirmed  by  many  other  authori- 
ties). I  need  not  prolong  this  history;  suffice  it  so  say  that 
she  never  got  well ;  for  years  I  saw  her  occasionally;  she 
always  had  rectal  symptoms  and  suffered  a  great  deal  of 
pain.  I  do  not  think  the  ulceration  of  the  bowel  ever 
entirely  healed.  I  took  her  into  St.  Mark's  Hospital  in  the 
year  1867,  and  by  rest  and  treatment  she  got  better,  but  not 
well ;  for  the  last  three  years  I  have  lost  sight  of  her.  I 
believe  she  gained  admittance  into  one  of  the  hospitals  for 
incurables.  I  am  quite  certain  of  one  thing,  /.  ^.,  she  was 
not  benefited,  and  I  am  strongly  of  opinion  that  she  was 
damaged,  by  the  operation  I  performed  upon  her. 

Emma  N — ,  was  admitted  into  the  Great  Northern  Hos- 
pital, under  my  care,  in  February  of  1864;  she  was  a  single 
women,  aet.  24.  She  complained  of  great  pain  in  passing 
her  motions;  the  pain  lasted  for  hours,  and  then  gradually 
subsided,  and  she  was  easy  until  she  had  again  to  go  to  stool. 
Of  course  my  diagnosis  was  fissure,  and  I  was  correct,  but  in 
addition  I  found  three  large  internal  arterial  haemorrhoids.  I 
incised  the  fissure  and  tied  the  piles.  She  went  on  very  well 
and  left  the  hospital,  feeling  quite  comfortable,  and  free 
from  pains  in  the  bowels  acting.  In  about  a  month  she 
came  again  to  me,  saying  that  her  old  symptoms  had  returned, 
but  on  examination  I  could  find  no  fissure  or  ulceration,  or 
anything  the  matter  with  the  rectum;  she  complained  of  pain 
and  straining  when  the  bowels  acted,  and  a  sensation  of  not 
being  relieved  afterwards.     The  only  thing  I  could  find   to 


INTERNAL    HEMORRHOIDS.  83 

account  for  this  was  a  tendency  to  intussusception  of  the  up- 
per part  of  the  rectum  on  her  bearing  down.  I  treated  her 
with  laxatives;  sedative  injections,  suppositores,  and  other 
remedies,  but  with  very  little  benefit  ;  what  seemed  to  do 
her  most  good  was  rest  in  bed.  Suspecting  uterine  disease, 
I  recommended  her  to  see  an  obstetric  physician,  and  she 
came  under  the  care  of  my  friend  Dr.  Palfrey,  and  that 
gentleman  found  that  she  had  retroflexion  of  the  uterus. 
She  was  under  his  charge  for  a  very  long  period,  and  under- 
went some  operative  treatment  at  the  London  Hospital, 
After  this  I  took  her  into  St.  Mark's  Hospital,  but  could 
never  find  any  organic  mischief  in  the  rectum,  although  she 
still  suffered  pain  and  much  discomfort  in  connection  with 
defecation,  I  have  recently  heard  that  this  patient  is  much 
better,  but  for  years  she  was  incapable  of  doing  any  work. 
It  was  said  that  masturbation  was  the  primary  cause  of  these 
women's  sufferings;  it  might  be  so,  but  I  cannot  say  that  I 
am  prepared  to  endorse  that  opinion, 

Mrs.  R — ,  a  patient  of  my  friend,  Mr.  Charles  Waller,  of 
Sydenham,  was  operated  upon  by  me  for  severe  haemorrhoids, 
Mr.  Waller  assisting  me.  I  knew  this  lady  was  suffering,  at 
the  same  time,  from  vaginismus,  but  I  thought  the  removal 
of  the  rectal  disease  might  be  generally  beneficial  to  her 
health,  which  was  very  much  deteriorated  by  the  losses  of 
blood  she  sustained.  After  the  operation  she  was  much  bet- 
ter for  a  few  weeks,  but  the  wounds  in  the  bowel  healed 
with  great  difflculty,  and  after  some  time  she  had  a  good 
deal  of  pain  on  defecation  and  the  bowels  were  very  con- 
fined; I  could  not  discover  any  disease  of  the  rectum, 
although  her  symptoms  were  directly  referable  to  that  organ. 
A  year  or  so  she  was  operated  upon  by  Dr.  Barnes  for  the 
cure  of  the  vaginismus;  but  I  know  that  she  has  never 
recovered  good  health,  and  is  an  invalid  to  this  day,  her 
sufferings  being  most  prominently  rectal. 

Tripartite  disease  of  the  rectum,  uterus,  and  bladder  or 
urethra,  is  very  common.  I  attended  a  lady  of  middle  age 
who  had  haemorrhoids  and  fissure  ;  after  the  operation  she 
still  suffered  pains  in  the  rectum  and  I  suspected  disease  of 
the  womb,  as  she  had  difficult  and  painful  menstruation. 
She  was  seen  by  a  distinguished  gynaecologist,  who  found  a 
contracted  os  uteri,  and  she  underwent  an  operation  which 
for  a  time  did  good;  then  she  suffered  from  spasm  of  the 
urethra  and  great  pain  on  micturition.  Dilatation  of  the 
urethra  was  performeji  also  with  temporary  benefit,  but   her 


84  INTERNAL    HAEMORRHOIDS. 

rectum,  although  perfectly  sound,  was  every  now  and  again 
very  painful,  and  always  so  at  her  menstrual  period.  I  know 
this  lady  consulted  most  of  the  eminent  men  in  London,  and" 
had  all  kinds  of  treatment,  and  still  she  comes  to 
me  from  time  to  time — it  is  quite  five  years  since  I  first  saw 
her — with  all  her  old  symptoms,  not  merely  subjective,  but 
objective  as  inflammation  of  the  rectum,  uterus,  bladder,  and 
urethra.  One  or  all  at  the  same  time. 

I  have  had  a  lady  under  my  care,  sent  me  by  my  friend 
Dr.  Leeson,  who  suffered  from  subinvolution  of  the  uterus, 
with  ulceration  of  the  os  and  painful  profuse  menstruation; 
she  had  also  haemorrhoids,  which  prolapsed  and  bled,  and  a 
circular  ulcer  in  the  bowel.  It  was  agreed  that  an  opera- 
tion should  be  performed,  and  I  removed  her  haemorrhoids 
with  the  clamp  and  cautery,  and  incised  the  ulcer.  The 
healing  was  most  difficult  and  tedious;  ulceration  took 
place,  and  such  contraction  as  to  cause  stricture,  which  after 
some  months  I  was  compelled  to  divide.  She  also  acquired 
inflammation  of  the  bladder,  after  having  a  catheter  passed 
only  a  few  times,  so  that  great  pain  on  micturition  was  added 
to  her  other  troubles;  only  after  the  most  constant  atten- 
tion, and  compelling  her  to  occupy  the  recumbent  position 
for  more  than  four  months,  did  she  recover.  Parallel  cases 
are  so  common  with  me,  that  I  could  relate  many  more,  but 
I  only  want  to  show  how  complicated  and  difficult  to  treat 
these  cases  are. 

In  cases  of  haemorrhoids  in  persons  with  congested  livers, 
or  who  habitually  eat  and  drink  too  much,  I  make  a  rule  of 
administering  every  night,  before  the  operation  (for  three  or 
four  nights),  a  five-grain  blue  pill,  and  in  the  morning  a 
modification  of  the  old-fashioned  black  draught.  This  may 
seem  to  be  rather  rough  treatment,  but  I  see  the  most  bene- 
ficial results  accrue  from  it;  and  I  am  confident  that  patients 
thus  served  do  better  than  many  others;  again  and  again  I 
have  been  perfectly  astonished  at  the  rapidity  with  which 
they  recover.  My  friend.  Dr.  David  Young,  of  Florence, 
has  recommended  glycerine  to  be  taken  internally  as  an 
effective  remedy  in  haemorrhoids,  even  of  advanced  growths. 
Knowing  what  an  accurate  observer  Dr.  Young  is,  I  have, 
now  in  many  hundreds  of  cases,  prescribed  his  remedy,  but 
I  am  bound  to  say  without  any  marked  success,  although  I 
have  persevered  with  it  for  months  continuously. 


OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS.  85 

CHAPTER  IX. 

OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS. 

When  you  have  determined  that  there  is  no  constitutional 
impediment,  and  that  an  operation  is  positively  necessary  to 
effect  the  cure  of  your  patient,  yoy  will  then  have  to  decide 
what  proceeding  will  be  the  best  suited  to  the  case  you  have 
in  hand.  From  this  you  will  conclude  that,  in  my  opinion, 
no  particular  method  of  operating  can  be  always  wisely 
employed  to  the  exclusion  of  all  other  modes. 

There  are  several  distinct  operations  and  modifications  of 
them  from  which  to  choose,  and  most  of  them  have  been 
advocated  by  surgeons  of  repute,  well  skilled  in  their  art, 
and  worthy  of  consideration.  I  shall  first  name  the  opera- 
tions and  then  proceed  to  describe  them,  and  I  trust  fairly 
to  express  my  opinion  as  to  their  various  merits  or  demerits. 

1.  Excision  with  knife  or  scissors. 

2.  The  ecraseur  of  Chassaignac  or  the  wire  of  Maison- 
neuve. 

3.  The  application  of  various  acids  and  caustic  pastes. 

4.  The   injection    of   carbolic   acid  or  other  caustic  or 
astringent  fluids  into  the  body  of  the  pile. 

5.  Cauterization,"  ponctuee  "  of  Demarquay,  Mr,  Reeves, 
and  others. 

6.  Cauterization,  "  linear  "  of  Woillemier. 

7.  Removal  by  the  galvanic  cautery  wire. 

8.  Removal   by  the  clamp   and   scissors,  appplying   the 
actual  cautery  to  arrest  haemorrhage. 

9.  Dilatation  of  the  sphincter  muscles. 

10.  Removal  by  means  of  the  screw-crusher. 

11.  Ligature. 

I.    EXCISION    BY    THE    KNIFE    OR    SCISSORS. 

In  days  gone  by  excision  was  performed  by  Dupuytren, 
Sir  Astley  Cooper,  and  others,  but  they  all  acknowledged 
the  danger  of  the  operation,  and  many  fatal  cases  are 
recorded  as  having  occurred  even  in  the  hands  of  masters  in 
surgery.  With  our  newly  devised  modes  of  operating,  and 
especially  of  arresting  hemorrhage,  we  can  now  in  many 
cases  perform  the  operation  of  excision  without  incurring 
any  extraordinary  danger,  and  therefore  it  need  not  be  sum- 
marily dismissed  from  our  consideration. 


S6  OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 

For  my  own  part,  I  think  it  is  one  of  our  best  operations, 
and  I  have  now  records  of  seventy  cases  in  which  I  excised 
internal  piles  with  remarkably  good  results.  Little  pain  has 
been  experienced,  and  the  recovery  has  been  so  rapid  that 
nearly  all  my  patients  have  been  absolutely  well  by  the  sixth 
day;  by  this  I  mean  that  the  wounds  were  all  soundly 
healed.  I  consider  this  the  only  test  of  perfect  recovery  ;  to 
say  that  they  were  convalescent  and  could  go  about  would 
not  express  the  whole  truth;  the  word  "  convalescence  "  is 
very  elastic  as  regards  its  significance,  and  is  often  erron- 
eously used  as  synonymous  with  "cured."  I  do  not  recom- 
mend excision  in  cases  where  the  haemorrhoids  are  very 
large  or  unusually  numerous.  In  my  cases  there  existed  one, 
two,  or  at  most,  four  piles.  In  performing  excision  I  first 
gently  but /////>'  dilate  the  sphinctei  muscles,  and  employ  a 
retractor  to  keep  the  anus  well  oper  I  then  seize  the  pile 
deeply  by  its  base,  cut  it  off  above  the  level  of  the  volsel- 
lum,  and  do  not  let  it  go  until  all  bleeding  is  arrested  by 
torsion  of  the  arteries;  rarely  more  than  two  vessels  spout 
and  require  twisting.  I  wiait  for  a  little  while  to  see  that  all 
bleeding  has  ceased,  and  then  I  treat  the  other  piles  in  a 
similar  manner.  After  all  the  arteries  have  ceased  to  bleed, 
I  place  a  piece  of  cotton  wadding,  previously  saturated  in  a 
solution  of  tannin  and  water  (strength,  one  ounce  of  tannin 
to  one  ounce  of  water),  within  the  anus,  as  higH  as  my  scis- 
sors have  cut.  In  no  case  did  any  recurrent  haemorrhage 
take  place.  This  operation  must  be  done  slowly  and  care- 
fully, and  therefore  occupies  more  than  the  usual  time, 
which,  however,  is  of  no  moment,  as  the  patient  is  insensi- 
ble. As  far  as  my  present  experience  can  lead  me  to  judge, 
I  am  of  opinion  that  numerous  cases  are  amenable  to  this 
treatment.  The  single  perineal  hasmorrhoid,  so  frequently 
found  in  women,  is  peculiarly  well  suited  to  this  operation. 
I  have  used  several  times  the  ingenious  toothed  scissors  of 
Dr.  Ric^iardson,  but  I  do  not  like  them.  The  theory  upon 
which  they  have  been  constructed  is  excellent,  but  the  prac- 
tice is  bad,  the  haemorrhage  is  not  always  controlled,  and 
often  very  nasty,  irritable  wounds  result. 

II.  THE  CHAIN  OR  WIRE  ECRASEUR. 

I  really  do  not  know  any  sufficient  reason  for  the  contin- 
ued, practice  of  this  mode  of  operating  on  piles.  I  have 
called  it  "  barbarous  and  unsurgical,"  and  I  cannot  see  why 
r  should  modify  that  expression.     The  chain  is  undoubtedly 


Of>ERATlONS    UPON    INTERaAL    HAEMORRHOIDS.  87 

worse  than  the  wire,  but  neither  is  definite  in  its  action;  they 
remove  either  too  much  or  too  Uttle.  Thus  I .  have  seen 
several  cases  of  most  intractable  stricture  follow,  and,  on  the 
other  hand,  cases  in  which  nothing  curative  had  resulted,  a 
timid  operator  taking  away  only  two  or  three  portions  of 
mucous  membrane,  and  really  leaving  the  haemorrhoids 
almost  untouched.  A  Brazilian  gentlemen  was  sent  to  me 
eight  weeks  after  he  had  been  operated  on  by  a  distinguished 
French  surgeon  with  the  ecraseur;  the  hemorrhoids  still 
existed  in  abundance,  and  he  was  losing  much  blood.  I  have 
seen  at  least  half  a  dozen  such  failures.  A  metropolitan 
surgeon  of  eminence  told  me  he  had  obtained  success  with 
ecraseur,  but  upon  interrogation  his  idea  of  success  did  not 
come  up  to  my  notion  of  the  word.  Another  objection  to 
ecraseur  in  haemorrhoids  is  the  intense  and  prolonged  pain 
which  follows,  especially  when  skin  is  removed.  An  Italian 
surgeon  related  to  me  a  case  where  death  ensued  in  a  woman 
from  shock  and  pain  in  less  than  twenty-four  hours,  and  I 
can  quite  credit  his  statement.  I  once  saw  a  woman  die  in 
St.  Thomas'  Hospital,  from  the  same  cause,  after  an  opera- 
tion by  ligature  applied  in  the  old  way,  I  mean  by  trans- 
fixion and  ligature  or  skin  as  well  as  haemorrhoids.  The 
patient  was  operated  upon  by  Mr.  Simon  on  the  19th  of 
November,  1859.  She  was  a  pale,  feeble  woman^  aet.  53; 
she  died  on  the  morning  of  tne  next  day;  she  had  suffered 
intensely.  I  have  no  note  of  what  was  d.one  to  relieve  the 
pain.  The  post-mortem  examination,  made  by  Dr.  Sydney 
Jones  on  the  21st,  was  as  follows: — 

"  Some  piles  had  been  the  subject  of  operation  by  liga- 
ture; the  ligatures  were  present.  Nothing  abnormal  was 
detected  in  the  veins  leading  from  the  ligatured  piles.  The 
thoracic  viscera  were  healthy.  There  was  some  congestion 
of  the  posterior  part  of  the  lungs.  The  liver  was  rather 
large  and  pale.  The  kidneys  were  healthy.  The  perito- 
neum and  intestines  were  quite  healthy." 

I  do  not  think  the  death  in  this  case  could  be  attributed 
to  anything  but  shock  and  exhaustion   from  excessive  pain. 

III.    THE    APPLICATION    OF    VARIOUS    ACIDS    AND    CAUSTIC 

PASTES. 

The  treatment  of  haemorrhoids  by  acids  or  caustics  may 
scarcely  seem  to  justify  the  use  of  the  term  "  operation,"  but 
as  some  manual  dexterity  is  necessary  in  order  to  apply  them 
properly,  I  must  beg  permission  of  my  readers  to  allude  to 


88  OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 

them  here.  For  many  years  acids  have  been  used  in 
attempts  either  to  destroy  or  cause  such  consolidation  in 
piles  as  should  lead  to  their  cure.  The  acids  chiefly  used 
have  been  the  fuming  nitric  acid,  the  acid  nitrite  of  mur- 
cury,  chromic;  and  more  recently  carbolic  acid.  It  was 
thought  at  one  time  that  even  large  piles  could  be  destroyed 
by  acids,  and  many  cures  were  published,  but  I  very  much 
doubt  if  any  lasting  cures  of  developed  haemorrhoids  were 
affected  by  such  means.  I  have  seen  numbers  of  cases  in 
which  the  attempt  was  made,  but  the  patients  were  either 
not  relieved  at  all,  or  only  very  temporarily  benefited. 
Haemorrhage  was  often  arrested,  but  it  generally  recurred, 
and  on  many  occasions,  after  the  free  use  of  acid,  violent 
bleeding  took  place  on  the  separation  of  the  sloughs,  and 
patients  were  brought  nearly  to  death's  door.  If  the  appli- 
cation of  acids  were  restricted  to  cases  of  small  granular 
piles,  or  patches  .of  villous,  bleeding,  mucous  membrane,  I 
should  not  object  to  their  use,  as  often  patients  will  submit 
to  such  treatment  when  they  will  not  to  anything  more  for- 
midable, and  relief  and  even  cure  in  this  stage  of  disease  may 
be  obtained;  but  no  satisfaction  can  result  from  touching 
large  haemorrhoids  with  any  acid  known  to  me.  A  few  years 
ago  I  had  an  opportunity  of  testing  all  the  acids  I  have  men- 
tioned, in  the  case  of  an  old  Indian  general,  who  had  three 
prolapsed  arterial  haemorrhoids  of  vascular  surface  and  con- 
siderable size.  His  shattered  health,  with  partial  paralysis, 
forbade  any  serious  operation,  and  he  was  unwilling  that 
more  than  external  applications  should  be  made.  For  three 
months  I  persevered;  I  managed  not  to  cause  him  much 
pain,  though  the  diseased  mucous  surfaces  were  painted 
freely  and  frequently.  The  method  in  which  I  applied  the 
acids  I  will  mention,  as  I  think  it  a  good  way  to  avoid  pain. 
The  piles  being  fully  prolapsed  (he  could  strain  them  down 
easily),  I  surrounded  one  with  a  piece  of  wool  soaked  in  a 
saturated  solution  of  bicarbonate  of  soda;  the  surface  of  the 
pile  was  then  dried,  and  the  acid  applied  with  a  small 
wooden  brush  several  times,  waiting  between  the  applications 
for  the  part  to  dry.  Each  pile  being  thus  treated  the  parts 
were  washed,  well  oiled,  and  returned  within  the  sphincters. 
On  one  or  two  occasions  troublesome  bleeding  followed  the 
separation  of  a  slough,  but  usually  it  came  away  in  small 
portions;  by  this  mode  of  using  the  acids  I  never  caused  any 
burning  of  skin  or  healthy  structure.  At  times  the  patient 
thought  himself  better,  but  the  final  result  was  a  failure. 


OPERATIONS    UPON    INTERNAL    HEMORRHOIDS.    ,        89 

I  came  to  the  conclusion  that  the  chromic  and  carboHc 
acids  were  better  agents  than  nitric  acid  and  acid  nitrate  of 
mercury.  Still  more  recently  I  had  a  good  trial  with  acids 
on  a  gentleman  who  one  haemorrhoid  placed  anteriorly,  which 
was  always  prolapsed,  and  consequently  bled,  and  gave  him 
much  annoyance,  but  no  great  pain.  I  really  expected  to 
obtain  a  fair  result  here  but  all  failed.  My  friend,  Dr.  B. 
W.  Richardson,  had  recommended  me  to  try  the  application 
of  his  "  Iodized  Colloid"  as  a  remedy  in  internal  haemor- 
rhoids; he  told  me  the  resulting  pain  would  be  considerable, 
but  that  a  dozen  touches  would  generally  suffice  for  the  cure. 
I  made  trial  of  this  in  the  above  case,  but  the  pain  experi- 
enced was  so  great  that  my  patient  became  restive  and 
refused  to  persevere;  while  in  that  humor  I  suddenly  pro- 
posed to  excise  the  offending  pile;  he  consented;  I  at  once 
removed  it,  twisted  the  vessels,  and  he  was  quite  well  in  a 
few  days. 

Caustic  Pastes. — Personally  I  have  had  no  experience  in 
this  practice  as  applied  to  haemorrhoids,  but  in  France  and 
Germany  it  has  been  freely  recommended;  to  my  mind  the 
uncertainty  of  the  result,  added  to  the  great  pain  inflicted 
by  caustics,  is  sufficient  to  deter  me  from  using  them. 

Caustic  pastes  are  mostly  formed  by  adding  an  inert 
material  to  some  chlorides,  zinc,  calcium,  etc.  Ricord's  paste 
(sulphuric  acid  and  carbon)  is  a  favorite  with  some 
surgeons. 

Dr.  Laroyenne  of  Paris,  in  the  Gazette  Hebdojnadaire  de 
Me'decine,  No.  34,  1872,  passes  in  review  the  usual  methods 
of  treating  bleeding  internal  piles,  and  considers  them  all  to 
have  many  objectionable  features  and  dangers,  and  recom- 
mends, as  Bonnet  and  Valette  have  done,  the  use  of  Vienna 
paste  and  chloride  of  zinc;  but  instead  of  applying  the  caus- 
tic all  over  the  pile,  he  uses  it  in  the  following  manner: 
When  the  partis  prolapsed  several  lines  are  drawn  along  the 
surface  of  each  haemorrhoid  with  Vienna  paste,  the  lines  con- 
verging towards  the  orifice  of  the  anus.  After  two  or  three 
minutes  the  application  is  followed  by  placing  small  frag- 
ments of  chloride  of  zinc  paste  where  the  Vienna  paste  has 
been.  Eight  or  ten  caustic  lines  are  sufficient  to  cure  the 
largest  prolapse.  In  this  manner  deep  radiating  cauteriz-a- 
tions  are  produced  without  destroying  much  of  the  surface 
of  the  piles.  The  application  remains  for  seven  or  eight 
hours.  The  only  painful  period,  -says  Dr.  Laroyenne,  is  dur- 
ing the  application  of  the  Vienna  paste.     He  has  employed 


90  OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS. 

this  method  fourteen  times  without  the  sHghtest  ill  effects 
resulting,  all  the  patients  being  cured,  and  he  believes  the 
treatment  to  be  less  often  followed  by  haemorrhage,  pyaemia, 
and  other  accidents,  than  any  other.  I  am  sorry  I  cannot 
concur  with  Dr.  Laroyenne,  and  submit  that  his  experience 
is  far  too  small  to  justify  his  belief. 

IV.  THE     INJECTION    OF    CARBOLIC     ACID     OR    OTHER     FLUIDS 
INTO  THE  SUBSTANCE  OF  THE  PILE. 

I  have  read  in  American  pamphlets,  that  the  injection  of 
carbolic  acid  into  internal  piles,  for  the  purpose  of  effecting 
radical  cures  is  very  commonly  practiced  in  America  and 
that  "shoals  of  quacks"  perambulate  the  country,  armed  with 
a  hyperdermic  syringe,  and  a  bottle  containing  a  so-called 
secret  remedy,  this  remedy  being  carbolic  acid  diluted  in  dif- 
ferent ways  and  of  different  strength;  the  favorite  formula  is 
equal  parts  of  strong  carbolic  acid,  glycerine  and  water.  This 
treatment  is  strongly  advocated  by  Dr.  Cook,  of  the  Ken- 
tucky School  of  Medicine,  who  obligingly  sent  me  his  essay 
upon  the  subject.  I  most  sincerely  hope  he  is  in  error  as  to 
the  "  shoals  of  quack"  who  employ  this  remedy  ;  but  if  radi- 
cal cures  are  affected,  and  no  evil  results,  the  only  objec- 
tion I  can  see  is  that  the  legitimate  practitioner  loses  his 
fees. 

After  carefully  reading  Dr.  Cook's  pamphlet  I  did  not  feel 
quite  satisfied  that  he  had  made  out  a  good  case  for  the  car- 
bolic acid  treatment  ;  in  fact  he  only  relates  the  histories  of 
two  persons  on  whom  he  had  performed  injection  ;  he  gen- 
erally uses  the  formula  I  have  mentioned,  and  squirts  through 
a  large  needle  ten  to  twenty  drops  of  the  solution  into  the 
substance  of  the  pile;  he  does  not  inject  all  the  haemorrhoids 
at  once,  but  one  or  two  at  a  time  every  other  day  until  all 
are  done.  Many  American  surgeons  who  came  to  see  the 
practice  at  St.  Mark's  have  repudiated  the  treatment  in 
round  terms,  and  call  it  uncertain  and  dangerous.  Dr. 
Matthews,  of  Louisville,  has  kindly  sent  me  his  pamphlet, 
read  before  the  Kentucky  State  Medical  Society  in  1878,  and 
in  that  paper  he  endeavors  to  show  that  the  injection  of  the 
acid  into  a  pile  is  painful  and  inefficient  and  that  death  is  to 
be  feared  {a)  from  peritonitis,  (3)  from  embolism,  {c)  from 
pyaemia.  In  support  of  his  assertion  he  relates  a  case  under 
the  care  of  another  i:)ractitioner,  where  in  twelve  hours  vio- 
lent inflammation  followed,  b'lt  the  piles  were  not  cured, 
for  in  twenty  days  after  the  injection  one  tumor  had  to  be 


OPERATIONS   UPON    INTERNAL    HAEMORRHOIDS.  9I 

removed  by  ligature.  He  also  cites  another  case  of  periton- 
eal inflammation,  and  says  embolism  and  pyaemia  have  been 
known  to  result  from  injecting  nsevi  with  solution 
of  iron,  and  death  have  occurred  from  injecting  inter- 
nal haemorrhoids  with  carbolic  acid.  For  my  own 
part  I  am  much  inclined  to  agree  with  the  opinion 
of  Dr.  Matthews.  I  tried  the  injecting  plan  on  some 
few  cases,  but  the  'result  was  much  pain,  more  inflam- 
mation than  was  desirable,  a  lengthy  treatment,  and  the 
result  doubtful  ;  certainly  not  a  radical  cure. 

It  appears  to  me  that  all  attempts  to  destroy  vascular 
growths  by  causing  coagulation  of  blood  or  inflammation  in 
them,  while  they  are  not  shut  off  from  the  general  circula- 
tion, must  be  fraught  with  danger.  You  can  have  no  guaran- 
tee that  the  coagulum  may  not  break  down,  and  minute  par- 
ticles of  dead  tissue  find  their  way  into  the  vascular  or  lym- 
phatic system  and  result  in  embolism  or  pyaemia,  or  both. 
Perchloride  and  persulphate  of  iron  in  solution  have  been 
used  in  the  same  manner  as  carbolic  acid,  but  a  similar  risk 
is  connected  with  them,  and  this,  I  submit,  far  outweighs 
the  advantages  they  are  said  to  offer. 

V.  CAUTERIZATION     "  PONCTUEE." 

As  far  as  I  can  ascertain,  M.  Demarquay,  in  the  year 
1868,  practiced  and  strongly  advocated  the  use  of  a  red-hot 
cautery  as  a  cure  for  internal  haemorrhoids;  the  iron  was  to 
be  thrust  deeply  into  the  pile  twice  or  thrice;  he  had  not 
much  success.  I  have  been  informed  by  several  friends  in 
military  and  civil  practice  that  the  native  doctors  in  China 
and  some  parts  of  India  treat  haemorrhoids  according  to  the 
plan  of  M.  Demarquay,  and  possibly  have  done  so  for  hun- 
dreds of  years.  My  informants  have  not  been  able  to  satisfy 
me  as  to  the  results  of  the  treatment,  only  my  friend.  Dr. 
Beaumont,  said  "  he  thought  that  many  died." 

In  1873  Enoch  Bottini,  of  Novare,  published  a  thesis 
entitled  "La  galvanico  caustico  nella  practica  Chirurgica." 
I  make  the  following  extract  on  haemorrhoids:  "The  opera- 
tor provided  himself  with  a  galvanic  cautery  heated  to  a  fine 
red,  applies  the  point  of  it  to  the  haemorrhoidal  tumor,  and 
introduces  it  slowly  and  progressively  to  a  depth  varying 
from  ten  to  fifteen  millimetres.  When  the  point  of  fire  has 
arrived  in  the  interior  of  the  tumor  he  moves  it  around 
allows  it  to  remain  for  a  few  seconds,  and  then  rotates 
as   it    is    withdrawn  ;    he    repeats    the    treatment    in    the 


92  OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 

same  manner  and  with  equal  precautions  to  all  the  piles. 
If  the  tumors  are  extensive  he  again  introduces  the 
cautery  parallel  to  the  rectum."  A  case  of  pyaemia 
following  this  operation  is  related  in  full  detail  by 
Verneuil.  A  similar  operation  was  performed  in  1873  by  E. 
Lartisen,  a  pupil  of  Verneuil.  Mr.  Reeves  of  the  Hospital 
for  Diseases  of  Women  has  brought  this  method  forward 
in  an  article  in  the  La7icet  of  Feb.,  1877.  He  calls  it  "  imme- 
diate" and  "  new  ;"  the  one  is  just  as  correct  a  definition  as 
the  other.  Wishing  to  see  whether  the  conical  cautery 
attached  to  the  ''  Paquelin"  instrument  was  better  than  the 
hot  iron  of  Demarquay  or  the  Chinese,  within  a  fortnight  of 
the  appearance  of  Mr.  Reeves'  paper  I  used  it  in  three  cases. 
One  was  a  patient  of  Dr.  Hills,  of  Abbey  Road,  St.  John's 
Wood,  another  was  a  case  which  I  left  to  the  late  Mr. 
Ernest  Carr  Jackson,  seeing  him  only  twice  or  so  myself, 
and  the  third  was  a  hospital  patient.  I  am  bound  to  say 
that  although  Meyer  &  !Meltzer  made  my  cautery,  and  I 
rigidly  followed  Mr.  Reeves'  directions,  these  cases  were 
all  failures  great  pain,  retarded  recovery,  and  abscesses  occur- 
red in  two;  in  one  a  cure  did  not  result.  I  was  only  pleased 
nothing  worse  happened  as  the  same  objection  applies  to 
this  mode  of  treatment  as  I  brought  against  the  use  of 
injections  of  acids  into  piles,  viz.,  you  produce  a  slough  or 
inflammation,  the  extent  of  which  you  cannot  measure  or 
control  in  the  interior  of  a  vascular  tumor  not  cut  off  from  the 
general  circulation. 

VI.    CAUTERIZATION,  "  LINEAR,"  OF  WOILLEMIER. 

The  operation  of  Woillemier,  I  think,  is  "unique,"  and  I 
feel  I  cannot  do  better  than  translate  from  V  U?iion  Medicate 
(1874)  such  portions  of  his  lecture  as  shall  make  his  method 
quite  clear  to  my  reader. 

I  must  express  my  pleasure  at  the  straightforward  manner 
in  which  M.  Woillemier  describes  the  advantages  and  disad- 
vantages of  his  operation.  He  does  not  hesitate  to  say  that 
the  patient  may  be  one  month  in  getting  w^ell,  he  states  that 
in  very  bad  cases  two  operations  may  be  necessary,  and  fur- 
ther considers  the  dangers  which  may  arise. 

''  The  patient,  whose  rectum  has  been  emptied  in  the 
morning,  by  means  of  an  injection,  ought  to  be  chloroformed; 
but  if  he  prefer  to  remain  awake,  it  is  of  little  importance, 
as  the  operation  lasts  only  some  seconds.  He  is  laid  on  an 
edge  of  the  bed,  with  one  leg  extended,  and  the  other  bent 


OPERATIONS   UPON   INTERNAL   HAEMORRHOIDS.  93 

as  if  he  were  going  to  be  operated  on  for  a  fistula.  The 
assistant  raises  the  disengaged  buttock,  the  surgeon  paints 
the  anus  and  the  surrounding  parts  freely  with  collodion, 
while  another  assistant,  by  means  of  bellows,  drives  off  the 
fumes  of  the  ether,  which  are  sure  to  catch  fire  when  a  highly 
heated  cauterizer  is  brought  near  them.  During  these  pre- 
parations, two  knife-shaped  cauterizers  have  been  placed  in 
a  small  furnace,  full  of  charcoal  or  burning  wood.  The 
blades  of  these  cauterizers  should  be  two  centimetres  long 
and  one  wide;  the  tip  and  edge  should  be  blunt,  as  in 
ordinary  cauterizers,  but  the  back  should  be  four  or  five 
millimetres  thick,  so  as  to  hold  enough  heat.  The  surgeon 
takes  one  of  these  cauterizers,  when  it  is  white  hot,  and 
introduces  it  about  one  centimetre  into  the  anus,  bearing 
with  the  shoulder  of  the  instrument  rather  more  on  the 
cutaneous  than  on  the  mucous  orifice,  and  makes  four 
cauterization  lines,  before,  behind,  on  the  right,  and  on  the 
left.  The  operation  is  terminated  when  it  has  lasted  five  or 
six  seconds.  The  patient  is  brought  back  to  consciousness, 
and  simple  water  dressings  only  are  applied  to  the  anus. 
We  must  premise  that,  under  the  influence  of  the  congestion 
produced  by  cauterization,  the  hsemorrhoidal'  tumor  will 
reappear  the  first  day  or  so,  and  may  sometimes  be  larger 
than  usual,  but  no  notice  need  be  taken  of  it.  We  can 
relieve  the  pain  of  the  patient,  pain  which  has  no  relation  to 
the  cauterization,  only  by  coating  over  the  hsemorrhoids  with 
a  narcotic  ointment,  and  covering  them  up  with  a  poultice. 
The  tumor  soon  ceases  to  be  painful,  aud  is  at  last  com- 
pletely and  spontaneously  retracted.  The  time  necessary 
for  cure  varies  only  according  to  the  size  of  the  haemorrhoids, 
the  relaxation  of  the  anus,  and  the  age  of  the  patient.  It 
has  never  exceeded  one  month,  and  has  sometimes  been 
much  less.  In  some  subjects,  even  when  circumstances 
have  made  success  doubtful,  cure  has  taken  place  as  in 
simple  cases.  The  patient  ought  to  be  chloroformed,  par- 
ticularly in  private  practice,  where  the  assistance  is  less 
efficient  than  in  a  hospital,  for  though  the  operation  is  rapid 
it  is  also  very  painful.  The  patient  may  struggle  after  one 
or  two  applications' of  the  cautery,  and  even  refuse  to  allow 
others  to  be  made,  so  that  the  operation  would  remain 
incomplete.  The  orifice  of  the  anus  and  the  surrounding 
parts  must  be  painted  with  collodion.  This  is  a  very  impor- 
tant precaution.  All  surgeons  have  affirmed  the  difficulty  of 
preventing  the  effects  of  radiated  heat.     To  preserve  the 


94  OPERATIONS   UPON    INTERNAL   HAEMORRHOIDS. 

parts  from  these  effects,  cloths  steeped  in  cold  water,  and 
thin  plates  of  wood,  have  been  used;  but  not  only  are  these 
in  the  operator's  way,  but  they  are,  as  a  rule,  inefficacious. 
Collodion,  on  the  contrary,  even  when  applied  in  a  thin 
layer  only,  forms  an  artificial  epidermis  scarcely  permeable 
to  heat  and  sufficiently  protecting  the  skin. 

"  It  is  necessary  to  dissipate  the  ether  vapor,  or  it  would 
take  fire  as  soon  as  the  heated  cauterizer  is  brought  near  the 
anus.  The  accident  would  not  be  of  much  importance,  for 
fhe  burning  vapor  is  easily  extinguished  by  blowing  it  out; 
but  it  is  better  to  avoid  it  altogether.  It  is  easy  to  under- 
stand the  importance  of  the  use  of  collodion  in  relation  to 
the  pain  which  succeeds  the  operation.  The  patient  cannot 
feel  pain  in  the  parts  to  which  the  iron  has  been  applied, 
for  the  tissues  are  dead,  but  he  suffers  in  the  surrounding 
parts  which  have  been  attacked  by  the  radiated  heat,  and 
the  painful  nature  of  superficial  burns  is  well  known.  The 
burns,  however,  are  not  very  serious,  and  the  pain  lasts  only 
about  four  days,  being  principally  felt  at  the  time  when  the 
inflammation  necessary  for  the  falling  off  of  the  sloughs 
develops  itself,  or  during  defecation  after  the  sloughs  have 
fallen  off.  T'he  cauterizers  ought  to  be  knife-shaped,  or 
even  with  round  points.  To  ensure  the  rapidity  of  the 
operation  they  should  be  heated  to  white  heat.  One  opera- 
tion is  frequently  enough,  but  more  than  two  are  never 
necessary,  how  large  soever  the  hsemorrhoidal  tumor  may 
be,  for  we  do  not  act  directly  on  the  latter,  but  on  the 
anus. 

"  In  some  cases  the  tumor  cannot  be  reduced  before  oper- 
ation, or  can  be  only  partially  replaced,  the  involuntary  con- 
tractions of  the  muscles  causing  it  again  to  protrude.  No 
notice  need  be  taken  of  this  accident.  The  cauterizer  is 
slipped  between  the  tumor  and  the  walls  of  the  anus,  for  it 
is  of  little  consequence  if  the  haemorrhoids  should  be  lightly 
cauterized  by  the  back  of  the  instrument. 

"  Sometimes  the  shoulder  of  the  cauterizer  implicates  the 
cutaneous  circumference  of  the  anus;  but  that  is  of  no 
importance;  it  is  even  sometimes  useful,  when  the  anus  is 
considerably  relaxed.  There  is  no  need  to  dread  haemor- 
rhage, for  the  cauterizer  interferes  only  with  the  mucous 
membrane,  the  submucous  cellular  tissue  at  the  entrance  of 
the  anus,  and  the  skin  at  the  edge  of  the  orifice.  At  all 
these  points  the  vessels  are  small,  and  when  the  haemor- 
rhoidal  tumor  is  touched  by  the  back  of  the  cauterizer,  it  is 


OPERATIONS   UPON    INTERNAL    HEMORRHOIDS.  95 

in  SO  light  a  manner  that  no  vessel  of  any  magnitude  can  be 
opened. 

"  If  any  accident  is  to  be  feared  it  would  be  stricture  of 
the  rectum;  but  the  four  cicatrices  which  have  been  formed 
at  the  entrance  of  the  anus,  although  possessed  of  great 
retractile  power,  are,  made  linear  and  in  the  direction  of  the 
intestine.  Between  them  are  intervals  occupied  by  highly 
elastic  tissue,  and  the  presence  of  these  renders  stricture 
impossible.  It  may  be  objected  that,  if  the  anus  remains 
sufficiently  dilatable,  the  patient  may  have  a  relapse.  This 
accident  is  certainly  not  impossible,  but  it  is  the  business  of 
the  surgeon  to  estimate  the  state  in  which  he  finds  his 
patient.  If  he  is  going  to  operate  upon  an  old  person  having 
a  large  and  old-standing  tumor,  and  whose  anus  has  little 
resilient  power,  he  should  lean  a  little  more  heavily  on  the 
cauterizer,  so  as  to  implicate  a  greater  thickness  of  tissue 
than  in  ordinary  cases;  by  this  procedure  he  will  be  sure  to 
avoid  a  relapse." 

I  will  only  remark  that  I  have  no  doubt  the  operation  is 
efficient.  The  recovery  is  rather  long,  and  the  pain  is  con- 
siderable, but  by  experiment  I  find  that  the  application  of 
collodion  does  away,  in  great  degree,  with  the  pain  usually 
inflicted  by  radiation  of  heat. 

VII.  OPERATION  BY  THE  GALVANIC  CAUTERY. 

The  galvanic  cautery  may  be  employed  for  the  removal  of 
haemorrhoids,  the  division  of  fistula,  and  other  surgical 
operations  about  the  rectum.  I  have,  myself,  some  personal 
experience  in  its  use.  I  fail,  however,  to  see  any  good 
reason  for  the  adoption  of  this  method  of  operating  in 
ordinary  cases.  If  a  cautery  be  required,  I  cannot  tell  why 
the  galvanically  heated  wire  should  be  preferable  to  an  iron 
heated  in  the  fire,  or  to  any  form  of  platinum  cautery  ren- 
dered hot  by  the  rapid  combustion  of  benzoline,  as  in  the 
"  Paquelin  "  instrument.  In  my  humble  opinion,  in  almost 
all  cases,  the  "  Paquelin  cautery  "  is  superior  to  any  other. 
As  a  matter  of  course,  the  person  working  the  cautery  must 
thoroughly  understand  the  mechanism  of  the  instrument, 
and  have  had  some  practice  in  its  use.  All  the  failures  I 
have  seen  with  it  have  been  consequent  upon  the  small 
knowledge  of  those  who  were  working  it.  An  expert  can  at 
an  instant  give  any  heat  you  may  require,  from  white  to 
black. 

The  galvanic  cautery  requires  a  cumbersome  battery  ;  it 


96 


OPERATIONS    UPON    INTERNAL    HiEMORRHOIDS. 


Fig.  5. 


is  exceedingly  apt  to  fail  ;  you  may  at  the  supreme  moment 
get  either  too  much  or  too  little  heat,  and  this  difficulty  will 
occur  even  in  the  hands  of  a  specially  trained  assistant. 
There  is  still  another  objection,  which  applies  chiefly  to 
simple  cases,  as,  for  example,  the  removal  of  piles  ;  there 
seems  an  amount  of  fuss  and  pseudo-scientific  show  about 
it,  which  to  my  mind  is  exceedingly  repugnant.  The  only 
battery  at  all  reliable  is  DanieJl's. 

VIII.  THE  REMOVAL  OF  HAEMORRHOIDS  BY  THE  CLAMP  AND 
SCISSORS,  THE  BLEEDING  BEING  ARRESTED  BY  APPLICATION 
OF  THE  HEATED  IRON. 

This   operation   is   generally  known   as   the  "  clamp  and 
cautery  "  operation,  and   is   now  most  frequently  associated 

with  the  name  of  Mr.  Henry  Smith, 
although,  in  truth,  it  was  devised  in 
its  entirety  by  Mr.  Cusack,  of  Dublin, 
and  was  first  introduced  into  London 
by  Mr.  Henry  Lee,  of  St.  George's 
Hospital.  In  its  performance,  each 
pile  is  seized  by  a  volsellum  and 
drawn  well  down  ;  the  clamp  is  then 
applied  so  as  to  embrace  its  base,  the 
portion  above  the  clamp  is  cut  off 
with  a  pair  of  scissors  curved  on  the 
flat,  and  a  cautery  iron  heated  to  a 
dull  red  heat  is  feely  applied  to  the 
stump  until  all  the  vessels  are  well 
seared. 

In  my  opinion,  this  operation  has 
little  to  recommend  it.  As  regards 
danger  to  life — after  all,  the  issue  of 
the  greatest  moment — as  far  as  my 
most  careful  researches  have  led  me 
to  a  conclusion,  it  is  quite  six^  times 
as  fatal  as  the  ligature  properly  and 
dexterously  applied. 
Mr.  Henry  Smith,  in  the  La^icet  of  April  20th,  1878,  has 
published  his  last  series  of  cases,  numbering  530  in  all ;  he 
acknowledges  4  deaths.  In  195  cases  operated  upon  by  me 
by  means  of  clamp  or  cautery,  I  have  had  2  deaths.  This 
result  is  the  more  to  be  regretted,  seeing  that  in  1600  cases 
of  ligature  combined  with  incision,  I  have  not  had  a  single 
death  from  any  cause  whatever. 


Mr.  Allingham's 
Clamp  for  Haemorrhoids. 


OPERATIONS   UPON    INTERNAL    HAEMORRHOIDS.  97 

X.      DILATATION    OF    THE   SPHINCTHl   MUSCLES. 

The  treatment  of  hasmorrhoids  by  the  complete  dilatation 
of  the  external  and  internal  sphincter  muscles  has  been 
strongly  advocated  in  France  by  many  eminent  surgeons, 
and  notably  by  Verneuil,  Fontan,  Panas,  Gosselin,  Monod, 
and  others. 

The  benefits  resulting  from  dilatation  seem  to  have  been 
accidentally  discovered,  and  I  cannot  admit  that  the  rectal 
physiology  of  Verneuil  gave,  by  any  means,  the  clue  to  this 
treatment.  For  my  justification  for  this  statement  I  must 
refer  my  readers  to  previous  pages  of  this  work. 

I  have  now  no  doubt  that  in  certain  cases  of  haemorrhoids 
dilatation,  fall  but  gentle,  of  both  sphincter  muscles  will  give 
wonderful  relief,  and  I  have  myself  in  many  cases  seen  great 
good  accrue  ;  but,  on  the  other  hand,  there  are  cases  in 
which  no  good  has  resulted,  and  reflection  would  lead  one 
to  conceive  that  such  would  almost  certainly  be  the  case. 

When,  for  example,  in  old-standing  disease,  the  haemor- 
rhoids easily  prolapse  at  stool,  and  on  walking,  stooping, 
coughing,  and  other  common  physical  acts,  the  sphincter 
muscles  become  so  dilated  that  more  dilatation  could  not 
possibly  mend  matters.  For  here  no  strangulation  or  pressure 
takes  place  ;  the  piles  themselves  are  large,  but  they  do  not 
swell  and  become  livid  when  outside  the  body,  and  the  dis- 
comfort and  suffering  result  not  from  any  "pinching,"  but 
from  the  exposure  of  mucous  membrane  to  accidental  friction 
or  injury,  and  from  the  mucous  and  muco-sanguineous  dis- 
charge, and  I  have  often  seen  such  cases  where  no  remnant, 
even,  of  the  sphincter  muscles  could  be  detected  ;  and  when 
the  haemorrhoids  were  returned  a  large  patulous  opening 
could  be  seen,  into  which  the  hand  might  easily  be  passed. 
To  cure  these  patients  it  is  necessary  not  only  to  remove  the 
growths,  but  often,  also,  to  obtain  contraction  of  the  anal 
orifice  by  applying  freely  the  hot  iron,  so  as  to  produce 
several 'linear  cauterizations,  after  Woillemier's  plan. 

The  cases  best  suited  to  dilatation  are  the  very  opposite 
to  those  just  described.  When  the  piles  protrude  they  are 
tightly  embraced  by  the  sphincter  muscles,  and  immediately 
become  swollen  and  livid,  and  perhaps  bleed  freely,  the 
patient  being  able  only  with  much  trouble  and  considerable 
pain  to  return  them.  Here  it  is  manifest  that  dilatation  of 
the  sphincters  may  afford  speedy  relief,  and  even  result  in  a 
cure.     In  such  a  case  the  muscles  around  the  lower  inch  or 


98  OPERATIONS   UPON    INTERNAL    HAEMORRHOIDS. 

SO  of  the  rectum  are,  from  irritation,  in  a  state  of  almost 
constant  spasmodic  contraction,  consequently  all  the  vessels 
are  engorged,  and  the  return  of  blood  from  the  rectum  is 
greatly  impeded,  and  the  haemorrhoids  grow  with  great  rapid- 
ity. Complete  dilatation  is  to  be  effected  in  the  following 
way  :  The  patient  being  fully  under  the  influence  of  ether, 
you  insert  both  thumbs  into  the  rectum  and  dilate  gradually, 
first  in  the  antero-posterior,  and  afterwards  in  the  opposite 
direction,  using  an  amount  of  force  sufficient  thoroughly  to 
overcome  the  spasm.  You  continue  to  manipulate  the 
sphincters  until  the  muscles  feel  as  if  reduced  to  a  thoroughly 
pulpy  condition  ;  care  must  be  taken  to  act  high  enough  up 
in  the  rectum  to  include  the  whole  of  the  sphincter.  The 
result  is  that  the  state  of  contraction  is  abolished  and  no 
spasm  can  occur  ;  in  fact,  for  the  time,  as  in  any  over- 
stretched muscle,  paralysis  has  been  induced.  With  practice 
and  great  gentleness  the  desired  result  may  be  accomplished 
without  tearing  the  mucous  membrane,  or  even  drawing 
blood,  but  a  little  extravasation  is  usually  noticed  around  the 
anus  for  a  few  days.  After  this,  place  an  opium  suppository 
in  the  rectum,  and  keep  your  patient  recumbent  in  bed. 
What  takes  place  ?  First,  all  the  blood  returns  freely  to  the 
liver,  no  stasis  remains,  the  piles  diminish  in  size,  the  pain 
passes  away,  and  in  four  or  five  days  your  patient  may  rise 
and  go  about  his  business  wonderfully  relieved.  If  at  the 
end  of  two  or  three  days  you  examine  the  sphincters,  you  will 
find  them  both  capable  of  acting,  though  gently  ;  there  is  no 
spasm.  When  you  insert  your  finger  the  muscle  closes  upon 
it,  but  does  not  grasp  it ;  the  spasm,  indeed,  which  before  the. 
operation  rendered  it  difficult  for  you  to  get  your  finger  into 
the  bowel,  has  gone,  and  with  care  and  judicious  treatment 
may  never  return,  in  which  case  the  patient  would,  at  all 
events,  for  a  considerable  time,  be  cured  of  his  haemorrhoids. 
When  in  addition  to  piles,  a  fissure  or  ulcer  exists,  more 
immediate  benefit  is  obtained,  as  great  pain  on  going  to  stool 
will  no  longer  be  felt,  and  in  the  majority  of  cases  the  sore 
place  will  heal.  In  the  early  conditions  of  haemorrhoids, 
when  there  is  little  or  no  protrusion,  and,  as  often  happens, 
only  occasional  loss  of  blood  and  spasm  of  the  sphincter, 
the  dilatation  will,  as  I  have  personally  found,  really  cure 
the  patient,  or  at  all  events  postpone  for  an  indefinite  time 
the  growth  of  the  haemorrhoids.  In  the  case  of  a  gentleman 
recently  under  my  care,  painful  internal  hemorrhoids  existed 
as  complication  of  cancer  of  the  rectum.     Careful  dilatation 


OPERATIONS   UPON    INTERNAL    HAEMORRHOIDS. 


99 


cured  the  hsemorrhoids  and  made  him  comparatively  com- 
fortable. 

In  properly  selected  cases  I  am  of  opinion  that  dilatation 
is  really  an  admirable  method  of  treatment,  devoid,  as  it  is, 
of  danger,  causing  only  trifling  pain,  and  not  keeping  the 
patient  in  bed  more  than  a  very  few  days. 

THE  TREATMENT  OF  INTERNAL  HEMORRHOIDS  BY  CRUSHING. 

In  the  Lancet  of  July  3d,  1880,  Mr.  George  Pollock,  of 
St.  George's  Hospital,  advocates  treatment  by  crushing.  He 
says:  "  It  is  now  some  two  or  three  years  since  I  commenced 
to  put  into  practice  my  views  as  to  crushing.  The  earlier 
attempts  to  crush  the  base  of  the  pile  were  partial  failures 
as  regarded  the  perfect  freedom  from  haemorrhage.  From 
want  of  proper  construction  the  clamp   did  not  effectually 

Fig.  6. 


K8D11U£2<  SE5EMANN  LONDON  j 


Screw-Crushing  Instrument. 

spoil  the  tissues  at  the  base  of  the  piles,  seldom,  however, 
were  more  than  two  or  three  ligatures  necessary,  and  there 
never  was  troublesome  or  recurring  haemorrhage  encoun- 
tered." Mr.  Pollock  proceeds  to  state  that  the  subsequent 
pain  is  much  less  than  ^hat  which  usually  follows  the  use 
either  of  the  ligature  or  of  the  clamp  and  cautery,  and  he 
recommends  the  crushing  pincers  designed  by  Mr.  Benham. 
A  plan  of  treatment  recommended  by  such  a  sound  surgeon 
as  Mr.  Pollock  I  could  not  but  consider  worthy  of  a  fair  and 
extended  trial,  and  I  at  once  procured  Mr.  Benham's  crusher 
and  immediately  commenced  to  operate,  following  strictly 
Mr.  Pollock's  directions.  After  operating  on  about  ten  cases 
at  St.  Mark's  Hospital,  I  came  to  the  conclusion  that  even 
Mr.  Benham's  instrument  did  not  sufficiently  crush  the  base 
of  the  pile,  and  that  more  or  less  haemorrhage  nearly  always 


lOO         OPERATIONS   UPON   INTERNAL    HEMORRHOIDS. 

resulted.  In  one  bad  case  concealed  bleeding  took  place 
(/.  e.  haemorrhage  into  the  bowels  without  any  escape  from 
the  anus).  Some  hours  after  the  operation,  the  patient  said 
he  must  go  to  stool,  and  he  evacuated  a  large  quantity  of 
arterial  blood,  and  this  haemorrhage  continued  until  the  clots 
were  got  rid  of  by  injection  of  cold  water,  and  plugging  the 
rectum  with  wool  and  perchloride  of  iron  was  resorted  to 
by  the  house  surgeon.  I  had  the  pleasure  of  consulting  Mr. 
Benham  with  regard  to  his  invention,  and  he  suggested  a 
modified  form  with  which  he  saw  me  operate  on  several 
cases  ;  still,  however,  the  crusher  did  not  on  all  occasions 
perfectly  arrest  hemorrhage,  although  I  kept  it  applied  in 
bad  cases  for  two  minutes.  My  son,  Mr.  Herbert  W.  Ailing- 
ham,  then  devised  a  new  form  of  crusher,  in  which  a  screw 
movement  was  substituted  for  the  lever  action  in  Mr.  Ben- 
ham's  instrument.  We  then  had  an  instrument  capable  of 
exercising  an  almost  unlimited  amount  of  crushing  power 
(see  the  woodcut).  A  good  many  were  made  before  any- 
thing like  perfection  was  attained,  but  now  I  believe  that  the 
screw-crusher  is  a  very  safe  instrument,  provided  that  due 
care  be  taken  in  operating.  The  crusher  is  made  of  solid 
steel,  forming  an  open  square  at  one  end,  between  the  sides 
of  which  a  second  piece  of  steel  slides  up  and  down.  This 
bar  is  connected  with  the  screw,  which  brings  it  firmly  home 
against  the  distal  end  of  the  square,  first  by  sliding  and  then 
by  screw-action,  and  exerts  great  crushing  power  upon  any 
tissues  which  are  brought  between  the  two  opposing  sur- 
faces. To  enable  the  instrument  to  be  cleaned,  the  handle 
can  be  opened  by  pressing  the  ends  of  the  levers  aa.  After 
use,  the  instrument  should  be  cleaned,  dried  and  oiled,  to 
ensure  its  easy  working. 

A  few  words  about  the  method  of  using  the  crusher.  As 
above  stated,  in  my  first  dozen  or  more  cases,  I  followed 
rigidly  Mr.  Pollock's  directions,  but  afterward  I  thought  it 
better  to  avoid  crushing  skin,  and  therefore  made  an  incision 
where  the  mucous  membrane  joins  the  skin.  I  also  com- 
menced the  opperation  by  gently  but  fully  dilating  the 
sphincters — a  plan  I  always  adopt  when  applying  a  ligature 
to  internal  piles.  The  haemorrhoid  is  drawn  into  the  screw 
crusher  by  means  of  a  volsellum  or  hook,  and  this  being 
entrusted  to  an  assistant,  the  screw  is  pushed  up  and  screwed 
home  as  tightly  as  thought  desirable,  the  projecting  portion 
of  the  pile  is  cut  off  with  the  knife  or  scissors,  and  the  pres- 
sure may  be  kept  up  as  long  as  the  operator  thinks  fit ;  I 


OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 


lOI 


Fig.  7. 


now  keep  the  instrument  applied  for  about  twenty-five 
seconds  only.  In  this  operation,  care  must  be  taken  not  to 
remove  too  much  tissue.  If  this  precaution  be  not  attended 
to,  some  amount  of  uncomfortable  contraction  is  sure  to 
take  place.  This,  in  my  experience,  is  one  drawback  to  Mr. 
Benham's  clamp  ;  the  instrument  is  large  and  difficult  of 
adjustment,  consequently  more  tissue  may  be  taken  away 
than  the  operator  is  aware  of.  Fig.  7  represents  the  spring- 
forceps  used  in  bringing  into  the  clamp  the  portion  of  pile 
to  be  removed. 

I  have  now  (1881)  operated  upon  72  patients, 
37  at  St.  Mark's  Hospital,  and  the  remainder  in 
private  practice.  I  shall  continue  to  employ  the 
crushing  method  in  selected  cases,  as  I  am  by  no 
means  convinced  of  its  universal  applicability  or 
advantage.  As  regards  freedom  from  pain,  I 
have  been  on  the  whole  disappointed  ;  in  some 
cases  there  was  but  little  suffering  directly  after 
the  operation,  but  great  pain  followed  every 
action  of  the  bowels  for  some  time.  In  others 
the  immediate  pain  was  quite  as  severe  and  pro- 
longed as  that  caused  by  the  ligature.  QEdema 
of  the  external  parts,  when  many  or  large  piles 
were  removed,  was  very  marked  in  nearly  all  my 
cases  ;  often  the  external  swelling  did  not  show 
itself  until  after  the  first  action  of  the  bowels. 
I  cannot  say  that  the  patients  recover  very 
rapidly  ;  my  average  at  St.  Mark's  in  thirty- 
seven  cases  was  twenty-three  days,  and  in  thirty- 
five  private  patients  the  average  was  twenty  days. 
Contraction,  so  as  to  require  the  use  of  bougies 
or  dilatation  by  the  finger,  occurred,  on  an  average,  once 
in  every  9  cases.  As  to  haemorrhage,  when  Mr.  Benham's 
clamp  was  used,  ligatures  were  necessary  in  nearly  all  severe 
cases,  and  in  two  the  bleeding  was  so  free  a  few  hours 
after  the  operation  as  to  necessitate  plugging  the  rectum  with 
a  tube.  I  cannot  say  that  with  the  screw-crusher  bleeding 
has  never  occurred,  but  it  has  not  done  so  to  any  extent, 
and  ligature  of  a  vessel  has  rarely  been  required,  torsion 
usually  sufficing.  On  the  whole,  in  my  opinion,  crushing  is 
a  satisfactory  method  of  removing  internal  piles,  and  is  in 
every  respect  superior  to  the  clamp  and  cautery.  I  am 
inclined  to  consider  it  a  safe  operation,  but  on  that  point  no 
definite  conclusion  can  yet  be  formed.     That  the  operation 


I02         OPERATIONS    UPON    INTERNAL    HiEMORRHOIDS. 

as  regards  snfety  to  life,  freedom  from  haemorrhage,  pain,  and 
troublesome  complications,  is  vastly  superior  to  the  ligature 
skillfully  applied  has  yet  to  be  proved,  and  cannot  be  admit- 
ted until  many  hundreds  of  operations  have  been  recorded. 

THE     TREATMENT      OF     INTERNAL     HEMORRHOIDS     BY 

LIGATURE. 

In  expressing,  as  I  most  unreservedly  do,  the  opinion  that 
the  ligature  is  the  safest,  easiest,  and  best  operation  for  the 
great  majority  of  cases  of  haemorrhoids,  I  must  be  under- 
stood to  mean  the  operation  usually  performed  at  St.  Mark's 
Hospital,  viz.,  ligature  combined  with  incision.  The  oper- 
ation was  devised  by  the  late  Mr.  Salmon,  and  has  been 
practiced  at  that  institution  for  more  than  forty  years.  I 
must  premise  that  in  all  operations  about  the  rectum,  but 
more  particularly  in  cases  of  piles,  it  is  essential  that  the  ali- 
mentary canal  should  be  thoroughly  cleared  of  its  contents. 
For  two  or  three'  days  prior  to  the  operation  some  mild  but 
efficient  purgative  should  be  taken,  and  it  is  well,  if  possible, 
to  have  an  enema  of  warm  water  administered  a  few  hours 
before  operating. 

In  cases  of  piles  I  prefer  the  patient  to  lie  on  the  right 
side,  on  a  hard  couch,  with  the  back  towards  the  light,  and 
the  knees  drawn  well  up  to  the  abdomen.  The  assistant 
should  stand  with  his  back  towards  the  patient's  head  and 
raise  the  upper  buttock  with  the  right  hand,  the  right  elbow 
being  at  the  same  time  hooked  over  the  pelvis  so  that  he  can 
control  movement  on  the  part  of  the  patient  and  keep  him 
in  good  position.  The  patient  being  thus  prepared  and  fully 
under  the  influence  of  the  anaesthetic,  I  now  always  gently, 
but  completely,  dilate  the  sphincter  muscles;  this  completed, 
the  rectum  for  three  inches  is  within  your  easy  reach,  and  no 
contraction  of  the  splincters  takes  place,  so  that  all  is  clear 
like  a  map  before  you.  The  haemorrhoids,  one  by  one,  are 
to  be  taken  by  the  surgeon  with  a  volsellum  or  pronged 
hook-fork  snd  drawn  down;  he  then  with  a  pair  of  sharp, 
strong,  spring  scissors,  separates  the  pile  from  its  connection 
with  the  muscular  and  submucous  tissues  upon  which  it 
rests;  the  cut  is  to  be  made  in  the  sulcus  or  white  mark 
which  is  seen  where  the  skin  meets  the  mucous  membrane, 
and  this  incision  is  to  be  carried  up  the  bowel,  and  parallel 
to  it,  to  such  a  distance  that  the  pile  is  left,  connected  by  an 
isthmus  of  vessels  and  mucous  membrane  only. 

There  is  no  danger  in  making  this  incision,  because  all  the 


OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS.  I03 

larger  vessels  come  from  above,  running  parallel  with  the 
bowel,  just  beneath  the  mucous  membrane,  and  thus  enter 
the  upper  part  of  the  pile.  A  well-waxed,  strong,  thin, 
plaited  silk  ligature  is  now  to  be  placed  at  the  bottom  of  the 
deep  groove  you  have  made,  and  the  assistant  then  drawing 
out  the  pile  with  some  decision,  the  ligature  is  tied  high  up 
at  the  neck  of  the  tumor  as  tightly  as  possible.  Be  very 
careful  to  tie  the  ligature,  and  equally  careful  to  tie  the 
second  knot,  so  that  no  slipping  or  giving  away  can  take 
place.  I  myself  always  tie  a  third  knot;  the  secret  of  the 
well-being  of  your  patient  depends  greatly  upon  this  tying — 
a  part  of  the  operation  by  no  means  easy,  as  all  practical 
men  know,  to  effect.  If  this  be  done,  all  the  vessels  must  be 
included.  The  silk  should  be  so  strong  that  you  cannot 
break  it  by  fair  pulling.  If  the  pile  be  very  large  a  small 
portion  may  now  be  cut  off,  taking  care  to  leave  sufficient 
stump  beyond  the  ligature  to  guard  against  its  slipping. 
When  all  the  haemorrhoids  are  thus  tied,  they  should  be 
returned  within  the  sphincter;  after  this  is  done,  any  super- 
abundant skin  which  remains  apparent  may  be  cut  off;  but 
this  should  not  be  too. freely  excised,  for  fear  of  contraction 
when  the  wounds  heal.  An  injection  of  Liq.  Opii  Sedativus 
may  be  administered,  or  a  suppository  of  half  a  grain  of 
morphia  made  with  gelatine  and  glycerine.  I  always  place  a 
pad  of  wool  over  the  anus,  and  a  tight  T-bandage,  as  it 
relieves  pain  most  materially  and  prevents  any  tendeney  to 
straining. 

It  is  advisable  to  commence  operating  upon  these  piles 
that  are  situated  inferiorily,  as  the  patient  lies,  in  order  that 
the  others  may  not  be  obscured  by  blood,  but  when  the  hasm-- 
orrhoids  are  numerous,  and  there  is  a  small  pile,  either 
anterior  or  dorsal,  as  is  frequently  the  case,  it  is  better 
to  tie  the  small  one  first,  as  there  is  danger  of  their  being 
overlooked,  and  if  they  are  left  they  are  likely  to  grow, 
and  a  return  of  the  piles  may  be  confidently  anticipated 
in  a  few  months.  I  have  seen  many  cases  in  which  this 
occurred. 

When  the  patient  takes  an  anaesthetic  it  sometimes  happens 
that  the  protruded  piles  slip  up  into  the  bowel  again.  I  have 
seen  inexperienced  operators  much  worried  by  this,  but  you 
need  give  yourself  no  anxiety  about  it;  when  the  patient  is 
fully  narcotized  carefully  dilate  the  sphincters  as  I  have 
before  recommended.  The  advantages  are  that  the  whole 
rectum  is  fully  exposed  and  even  every  abrasion  can  be  seen. 


I04         OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 

and,  secondly,  the  spasmodic  pain  after  the  operation,  by 
this  dilatation,  is  almost  entirely  done  away  with. 

Spasm  of  the  sphincter  muscle  is  in  a  great  degree  the 
cause  of  pain  and  its  long  continuance;  my  patients  now 
never  have  pain  after  about  three,  or  at  most,  four  hours. 
The  only  suffering  that  may  remain  is  caused  by  spasm  of 
the  levator-ani,  which  will  act  from  time  to  time,  and  a 
retraction  of  the  anus  into  the  rectum  takes  place,  attended 
with  momentary  darting  pain.  I  was  never  certain  why  it 
was  that  patients  who  had  suffered  long  from  large  protrud- 
ing piles,  which  they  could  not  keep  up,  scarcely  experienced 
any  pain  after  ligature;  now  I  know  that  the  sphincter 
muscle  caused  most  of  the  pain,  and  those  who  had  practi- 
cally no  sphincters  did  not  have  a  tithe  of  the  pain  the  per- 
son with  a  strong  sphincter  had. 

After  the  operation  the  bowels  should  be  confined  for 
three  or  even  four  days.  I  find  a  solid  one-grain  opium  pill 
given  half  an  hour  after  the  operation,  and  repeated  every 
two  hours  twice,  the  best  to  begin  with;  the  pill  arrests  or 
prevents  vomiting;  later  on,  if  required,  a  draught  may  be 
administered.     The  formula  I  often  use  is  the  following : 

5 .     Pulvis  Cretse  Aromat 3  j 

'  Tinct.  Opii  or  Liq.  Opii  Sedativus mxv 

Spt.  ^ther.  Nit 3  j 

Mist.  Camphorae ad |  iss 

To  be  taken  night  and  morning,  or  three  times  in  the  day, 
for  two  days. 

In  very  bad  cases  and  in  delicate  persons,  I  occasionally 
keep  the  bowels  quiet  for  a  much  longer  period  than  four 
days.  I  have  done  so  for  a  week  or  ten  days,  and  I  think, 
in  some  instances,  with  very  manifest  advantage.  The  diet 
at  first  should  be  light:  soup,  beef  tea,  a  little  boiled  fish, 
milk  gruel,  tea  and  toast,  will  be  quite  sufficient;  no  alcohol 
at  all  should  be  taken;  perfect  rest  in  the  recumbent  position 
enjoined.  On  the  third  or  fourth  night,  according  to  the 
state  of  the  patient,  a  mild  aperient  may  be  administered, 
and  followed  by  a  draught  or  a  carefully  administered  enema 
of  warm  gruel  in  the  morning,  and  after  it  has  acted,  a  more 
liberal  diet  may  be  allowed,  but  I  always  advise  abstinence 
from  wine,  beer  or  spirits,  unless  there  be  some  special  con- 
dition indicating  the  necessity  for  their  use. 

It  is  well  to  tell  your  patient  that  some  temporary^  and 
possibly  rather  acute,  pain  may  be  experienced  on  the  first 


OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS.  IO5 

action  of  the  bowels,  and  also  that  a  slight  discharge  of 
bl(j»od  may  take  place  (it  by  no  means  always  occurs)  ;  if  you 
neglect  this,  needless  alarm  is  often  created,  the  patient 
imagining,  if  he  sees  any  blood,  or  has  much  pain,  that  all 
his  old  trouble  has  returned. 

I  think  it  advisable,  though  not  absolutely  necessary,  that 
the  patient  should  keep  lying  down  until  the  ligatures  sepa- 
rate, which  process  almost  invariably  takes  place  about  the 
sixth  or  seventh  day,  occasionally  a  day  sooner,  very  rarely 
a  day  later.  If  the  ligatures  are  tied  tightly  and  the  incision 
has  been  free,  this  course  of  events  is  but  very  seldom 
departed  from.  I  have  been  in  the  habit  for  a  long  time  of 
giving  daily  a  gentle  pull  at  the  ligatures,  commencing  the 
day  after  the  bowels  are  first  relieved;  by  this  plan  the  liga- 
tures always  separate  on  the  fifth  or  sixth  day.  Active 
exertion,  even  after  the  separation  of  the  ligatures,  is  to  be 
deprecated  until  the  sores  left  in  the  rectum  are  healed;  a 
fortnight  or  a  little  longer  is  generally  about  the  time  required 
to  accomplish  this.  It  is  quite  unnecessary  that  the  patient 
should  be  kept  in  bed  all  this  time,  or  even  to  his  chamber — 
he  may  move  about  m  moderation  ;  but  I  am  certain  that 
a  too  speedy  resumption  of  the  erect  position  is  likely  to 
retard  the  cicatrization  of  the  wounds.  The  patient  is  con- 
valescent, but  not  quite  well. 

I  have  had  patients  who  have  gone  about  their  business 
with  ligatures  on  their  haemorrhoids,  and  have  sustained  no 
injury;  here  is  a  case  of  that  kind:  A  gentleman  on  the 
Stock  Exchange  was  operated  on  by  me  some  years  ago;  it 
was  rather  more  than  an  average  case;  five  ligatures  were 
applied.  On  the  day  following  the  operation  some  sudden 
turn  of  the  markets  rendered  it  absolutely  necessary  for  him 
to  go  to  town.  When  I  called  upon  him,  to  my  surprise  I 
found  that  he  had  left  home;  and  for  three  days  consecu- 
tively he  went  to  his  office  and  remained  there  for  five  hours 
transacting  his  business,  as  he  afterwards  assured  me,  with 
very  much  less  inconvenience  than  he  had  frequently  experi- 
enced before  the  operation,  when  the  piles  came  down.  He 
was,  in  the  end,  none  the  worse  for  his  temerity,  but  it  is  an 
example  by  no  means  to  be  commended  or  followed.  On 
another  occasion  a  naval  officer  found  himself  compelled  to 
go  on  board  his  ship  on  the  third  day  after  operation,  jour- 
neying to  Portsmouth  for  the  purpose.  This  gentleman  did 
not  suffer  any  serious  inconvenience.  Mr.  Quain,  in  his 
work,  relates  a  parallel  case.     It  is  no  uncommon  thing  for 


I06         OPERATIONS    UPON    INTERNAL    HEMORRHOIDS. 

me  to  have  patients  who  are  able  to  resume  their  ordinary 
occupation  on  the  eighth  or  ninth  day.  In  a  case  sent  me 
by  my  friend  Mr.  WiUiams,  of  Brentford,  who  also  assisted 
me  at  the  operation,  the  haemorrhoids  were  very  large,  and 
four  ligatures  were  applied,  but  there  was  no  superabundant 
skin  requiring  removal.  On  the  eighth  day  this  gentleman 
was  really  quite  capable  of  walking  a  distance,  and  was 
rather  surprised  that  I  requested  him  to  abstain  from  much 
exercise;  he  had  no  pain  or  any  symptom  to  indicate  that  he 
had  not  perfectly  recovered,  but  I  am  sure  it  would  have 
been  very  unwise  for  me  to  allow  him  to  do  as  he  wished. 
The  wounds  inside  the  rectum,  I  knew,  could  not  be  soundly 
healed,  and  the  delay  likely  to  be  occasioned  by  too  much 
exertion  or  standing  about  might  be  serious.  Under  these 
circumstances  the  sores  possibly  would  not  heal,  and  painful 
and  troublesome  ulceration,  very  difficult  of  cure,  might  be 
the  result.  For  years  I  have  digitally  examined  all  my 
patients  upon  the  thirteenth  or  fourteenth  day  after  the 
operation,  and  in  the  great  majority  I  have  not  found  the 
rectum  perfectly  sound;  constantly  some  unhealed  sore 
remains,  and  in  my  opinion  such  a  patient  cannot  be  said  to 
be  well  and  allowed  to  go  about  his  ordinary  avocations, 
without  incurring  considerable  danger.  The  veins  of  the 
rectum  are  destitute  of  valves,  and  only  badly  supported  by 
areolar  tissue;  these  sores,  therefore,  much  resemble  in  their 
conditions  varicose  ulcers  of  the  legs;  and  we  well  know  in 
such  cases  rest  in  the  horizontal  position  is  absolutely 
necessary  to  ensure  a  speedy  and  certain  cicatrization. 
AVhen,  from  alow  condition  of  health,  wounds  in  the  rectum 
are  long  in  healing,  ulceration  will  in  all  probability  take 
place,  with  contraction  as  an  almost  certain  result. 

Pain  after  the  operation  varies  according  to  the  constitu- 
tion and  nervous  sensitiveness  of  the  patient,  and  also  as  to 
the  condition  of  the  parts  before  the  operation;  but,  as  I 
have  said,  by  performing  gentle  and  full-dilatation,  pain  is 
almost  done  away  with.  Lately  I  had  three  cases  of  haemor- 
rhoids consecutively  with  my  friend  Mr.  Aiken,  and  really 
these  patients  scarcely  complained,  though  they  were  sensi- 
tive persons  who,  I  am  sure,  would  have  had  great  suffering 
under  any  other  method  of  operating.  The  rapidity  of  the 
cure  in  these  three  cases  was  very  remarkable;  one  gentle- 
man, more  than  sixty  years  of  age,  and  whose  skin,  from 
great  losses  of  blood,  had  become  quite  the  color  of  old  wax, 
was  well  in  a  fortnight,  the  wounds  being  perfectly  healed. 


OPERATIONS    UPON    INTERNAL    HAEMORRHOIDS.  I07 

Still  more  recently  a  gentleman,  aged  sixty-four,  who  was 
seen  by  me  with  Mr.  Leggatt,  positively  never  lost  an  hour's 
sleep,  and  averred  he  had  no  pain,  and  in  twelve  days  was 
fit  for  anything;  was  not  merely  convalescent,  but  all  the 
wounds  had  healed.  If  pain  should  be  acute  at  first,  push 
your  opium  or  hypodermic  injection  (Morph.  gr.  }(,  Atro- 
pine gr.  -gVj  is  my  favorite  formula).  A  sponge  wrung  out 
of  very^hot  water  and  applied  to  the  sacrum  nearly  always 
affords  relief,  and  however  sharp  the  pain  may  be  at  first  (it 
is  always  exaggerated  by  the  want  of  moral  control  brought 
about  by  the  inhalation  of  ether),  in  two  or  three  hours  it 
will  have  subsided,  and  you  may  comfort  your  patient  by 
the  assurance  that  the  worst  of  his  troubles  will  soon  be 
over,  and  the  pain  will  most  surely,  if  gradually,  become  less. 
After  the  ligatures  come  away,  I  always  direct  my  patients 
to  douche  the  anus  well,  night  and  morning,  with  cold 
water;  this  is  very  comforting,  and  materially  hastens  the 
convalescence. 

Every  now  and  then  you  may  have  retention  of  urine  fol- 
low the  operation;  in  most  cases  a  warm  hip-bath  will 
enable  the  patient  to  pass  water  in  the  morning;  if  not,  of 
course  a  catheter  must  be  introduced.  Straining  to  mictur- 
ate should  be  avoided  under  any  circumstances.  This 
retention  is  by  no  means  very  uncommon  in  women,  but  I 
have  found  it  occur  much  oftener  in  men.  It  may  be 
accounted  for  by  the  fact  that  the  male  urethra  is  so  much 
more  liable  to  stricture  than  the  female,  and  very  slight 
irritation  will  set  up  spasm  of  the  strictured  part  sufficient 
to  induce  retention.  After  a  few  days  the  power  to  pass 
water  will  return  ;  but  I  have  seen  retention  for  ten  days  or 
a  fortnight. 

It  sometimes  happens  that  after  a  severe  operation  upon 
internal  haemorrhoids,  contraction  takes  place  in  the  bowel 
on  the  healing  of  the  wounds.  This  contraction  is  not 
usually  at  the  anus,  nor  does  it  affect  the  skin,  but  mucous 
membrane  only;  time  alone  will  generally  remove  it,  but  as 
it  may  occasion  straining  and  distress  to  the  patient,  I  advise 
the  passing  of  a  bougie  for  a  few  nights,  or  what  answers  as 
well,  and  is  less  alarming,  I  direct  the  introduction  of  the 
fore-finger,  well  anointed,  into  the  bowel,  night  and  morning. 
In  rare  cases,  when  the  wounds  have  been  long  in  healing, 
and  also  if  a  great  deal  of  the  bowel  has  been  removed 
longitudinally,  a  tight  hour-glass  contraction  takes  place — 
usually  the  contracted  part  is  ulcerated — the  patient  suffers 


Io8         OPERATIONS   UPON   INTERNAL   HEMORRHOIDS. 

much  pain,  has  obstinate  constipation,  atid  cannot  sit  up 
without  a  sensation  of  bearing  down  and  great  discomfort. 
This  is  the  form  of  stricture  and  ulceration  which  I  have  so 
frequently  found  following  operations  "when  heated  irons  are 
applied.  I  very  often  see  this  result  in  the  practice  of 
others,  and  have  had  it  occur  in  my  own  cases.  To  get 
them  well  requires  great  attention,  gentleness  and  persever- 
ance; usually  constitutional  treatment  is  required  as  well  as 
mechanical;  the  patients  are  nearly  always  weak  and 
unhealthy,  often  strumous,  and  the  malady  is  more  common 
in  women  than  in  men,  and  the  uterus  therefore  usually 
requires  attention.  Subinvolution,  retroversion,  and  ante- 
version,  with  flexion  and  chronic  endometritis,  are  the  dis- 
eases, frequently  complicating  the  rectal  mischief,  and  no 
surgeon  can  hope  to  cure  those  patients  who  does  not  take 
into  consideration  the  state  of  the  uterus. 

I  do  not  think  in  the  whole  range  of  surgery  there  is  any 
procedure  worthy  of  the  name  "operation."  which  can 
show  a  greater  amount  of  success  or  smaller  death-rate  than 
the  ligature  of  internal  haemorrhoids. 

In  the  year  1865  I  published,  in  the  Medical  Times  and 
Gazette,  some  statistics  of  the  practice  at  St.  Mark's  Hospi- 
tal, which  showed  that  in  1763  operations  upon  haemorrhoids 
there  had  been  5  cases  of  tetanus,  4  occurring  in  the  spring 
of  1858,  2  in  March,  and  2  in  April.  Since  the  year  1858 
about  2250  operations  have  been  performed,  and  there  has 
not  been  any  case  of  tetanus  ;  -ana  in  the  4013  cases  there 
has  been  but  one  case  of  doubtful  pyaemia.  This  death 
occurred  in  Mr.  Gowlland's  practice.  An  old  Hebrew  was 
operated  on  for  bad  piles,  with  the  Hgature.  A  few  days 
after  diarrhoea  set  in  and  he  died  exhausted.  Pyaemia  was 
suspected,  but  no  necropsy  was  made,  as  the  Jews  object,  so 
there  is  still  an  element  of  uncertainty  in  the  case.  Since  the 
publication  of  the  last  edition  of  this  work  about  250  cases, 
have  been  operated  upon  without  a  single  fatal  case  or  any 
symptoms  of  pyaemia  or  tetanus.  The  in-patient  books  at 
St.  Mark's  have  been  excellently  kept,  and  any  one  interested 
in  the  matter  could  easily  satisfy  himself  that  the  statistics  of 
operations  and  deaths  resulting  are  worthy  of  entire  confi- 
dence. 

Let  us  see  how  the  matter  stands.  In  St.  Mark's  Hospi- 
tal the  death-rate  from  all  causes  in  operations  on  external 
haemorrhoids  by  ligature  during  a  space  of  more  than  forty 
years  is  just  i  in  670.     Now,  hospital  practice  is  notoriously 


OPERATIONS   UPON    INTERNAL    HEMORRHOIDS.  I09 

more  fatal  than  private  practice,  yet  what  a  brilliant  result 
has  been  obtained  !  Referring  to  the  four  cases  of  tetanus 
occurring  in  St.  Mark's  in  the  months  of  March  and  April, 
1858,  they  must  be  considered  quite  exceptional,  as  since 
that  year  no  case  of  the  disorder  has  appeared.  Mr.  Curling, 
in  his  work  on  "  Diseases  of  the  Rectum,"  says,  "  In  the  year 
1858  tetanus  was  very  rife  in  London."  I  have  the  good 
fortune  not  to  have  had  one  single  fatal  result  from  the  liga- 
ture, either  in  my  public  or  private  practice,  which  now 
extends  to  more  than  1600. operations. 

Copeland,  in  his  work,  mentions  that  he  had  only  seen  one 
death. 

Bushe  that  he  never  had  a  fatal  case  with  the  ligature. 

Sir  Benjamin  Brodie,  whose  experience  was  unusually 
large,  states  he  never  lost  a  case. 

Mr.  Smye  says,  "  In  the  whole  of  my  practice  I  never  met 
with  a  case  which  either  terminated  fatally,  or  even  threat- 
ened to  do  so. 

Mr.  Curling,  in  the  last  edition  of  his  work,  affirms 
*'that,  with  one  exception,  no  fatal  case  of  operation  by 
the  ligature  has  occurred,  either  in  my  public  or  private 
practice." 

Mr,  Quain  had  only  one  patient  succumb  in  his  practice 
with  the  ligature. 

Mr.  Ashton  has  not  recorded  a  single  death  from  his 
method  of  operating  by  ligature. 

My  colleague,  Mr.  Gowlland,  who,  in  all  probability,  has 
had  a  larger  experience  in  rectal  surgery  than  any  other  sur- 
geon in  London,  has  had  a  most  remarkable  success  with  the 
ligature  in  haemorrhoids  ;  and  after  a  prolonged  trial  with  the 
clamp  and  cautery,  he  finally  abandoned  it. 

My  friend,  Mr.  Alfred  Cooper,  with  large  opportunities  for 
arriving  at  a  correct  judgment,  informs  me  that  he  has  never 
had  a  fatal  case  with  the  ligature,  and  now  does  not  employ 
the  cautery.  My  remaining  colleague,  Mr.  Goodsall,  is  also 
at  one  with  me  in  preferring  the  ligature. 

Let  us  for  a  moment  see  what  our  American  confreres 
think  : — 

Gross,  in  his  great  work  on  surgery,  says  :  "  The  operation 
(ligature)  is  as  simple  of  execution  as  it  is  free  from  danger 
and  certain  in  its  results." 

Dr.  Van  Buren,  so  well  known  here,  and  whose  experience 
in  the  treatment  of  rectal  disease  is  very  extensive,  says  :  "  I 
have  never  had  and  unpleasant  symptom." 


no  COMPLICATIONS    OF    HAEMORRHOIDS. 

Bodenhamer  states  ;  "  I  have  yet  to  encounter  my  first 
serious  accident." 

I  could  go  on  citing  the  favorable  opinions  of  my  American 
friends  with  regard  to  the  safety  of  ligation,  but  I  feel  I 
need  not  add  anything  to  what  I  have  written  to  prove  the 
great  success  in  every  way  of  the  operation  when  properly 
performed,  and  when  the  patient  is  well  treated  and  placed 
in  good  hygienic  conditions.  It  must  be  clear  that  if  the 
death-rate  at  St.  Mark's  Hospital,  in  so  many  years,  has  been 
I  in  adout  670  cases,  equally  good  results  ought  to  be 
obtained  in  private  practice.  If  patients  are  placed  in  hos- 
pital wards  teeming  with  septic  poisons,  the  deaths  which 
take  place  cannot  be  justly  ascribed  to  the  operation. 

Mr.  Annan  dale,  of  Endinburgh,  in  the  Edinburgh 
Monthly  Journal^  for  June,  1877,  pubHshes  an  article  "  On 
the  Operative  Treatment  of  Internal  Piles,"  and  comes  to 
the  conclusion  that  the  clamp  and  cautery  is  the  safest  and 
best  operation.  That  Mr.  Annandale  cannot  base  his  con- 
clusions on  his  own  experience  is  quite  evident ;  for  he  says 
(p.  1080)  :  "  In  about  two  hundred  cases  of  this  operation 
(the  ligature)  I  have  met  with  at  least  four  instances  of  fatal 
pyaemia,"  a  fearful  mortality  in  such  an  operation.  And  he 
goes  on  to  say  that,  "  since  1872,  I  have  operated  with  the 
clamp  and  cautery  on  twenty-four  patients,  with  one  death  " 
— a  still  higher  rate  of  mortality.  Mr.  Annandale,  however, 
still  advocates  the  use  of  the  clamp  and  cautery,  while  by  his 
own  showing  he  has  had  a  greater  fatality  with  these  than 
with  the  ligature 


CHAPTER  X. 

COMPLICATIONS   OF    HEMORRHOIDS. 

Haemorrhoids  are  not  infrequently  complicated  by  the 
coexistence  of  other  affections  of  the  rectum.  I  have  often 
seen  piles,  polypus,  and  fissure  in  the  same  patient. 

I  will  mention  the  more  trequent  complications,  so  that  the 
reader  may  be  warned  against  the  error  of  being  satisfied  with 
merely  finding  his  patient  has  piles,  without  searching  to  see 
if  any  other  malady  be  present. 

Fissure  or  small  painful  ulcer  is  very  often  associated  with 


COMPLICATIONS   OF    HAEMORRHOIDS.  Ill 

haemorrhoids,  and  a  careful  examination  is  needed  to  detect 
it,  as  one  of  the  tumors  may  overlap  the  fissure  so  as  entirely 
to  conceal  it.  Always  suspect  fissure  or  ulceration  when  your 
patient  tells  you  he  suffers  pain  on  defecation,  or  pain  con- 
tinuing long  after  the  bowel  is  relieved. 

In  operating  on  haemorrhoids,  when  fissure  or  ulcer  was 
found  to  exist,  I  always  used  to  divide  the  superficial  fibres 
of  the  sphincter  muscles,  so  as  to  set  them  at  rest.  I  now 
find  this  unnecessary,  as  the  dilatation  I  make  of  those  mus- 
cles allows  the  fissure  or  ulcer  to  heal.  It  is  well,  in  these 
cases,  not  to  omit  examining  the  upper  part  of  the,  fissure, 
to  see  if  any  sinus  runs  up  from  it ;  if  so,  it  must  be  laid 
open. 

Fistula  is  not  so  common  a  complication,  but  I  have  often 
seen  it.  If  the  fistula  be  well  marked  there  is  no  difficulty 
in  the  diagnosis,  but  if  it  be  of  the  blind  internal  variety,  or 
if  the  external  orifice  be  very  small  and  concealed,  as  it  may 
be,  by  an  external  flap  of  skin,  it  is  quite  possible  to  overlook 
it.  I  have  frequently  met  with  examples  of  this.  I  will  relate 
a  case  in  point  : — 

A  gentleman  consulted  me,  on  the  recommendation  of  Sir 
Risdon  Bennett.  His  statement  was,  that  three  months  ago 
he  was  operated  upon  for  piles,  and  was  pronounced  by  his 
surgeon  to  be  cured,  but  he  still  had  occasional  pain  and 
throbbing  in  the  anus  ;  there  was  also  a  constantly  recurring 
discharge  which  soiled  his  linen  ;  it  ceased  for  a  day  or  two 
and  then  returned.  He  had  mentioned  this  to  the  gentleman 
who  operated  upon  him,  and  had  been  told  he  was  only  suf- 
fering from  a  little  weakness  of  the  bowel,  which  would  soon 
right  itself  ;  of  this,  however,  the  patient  could  not  feel  con- 
vinced, and  he  was  alarmed,  thinking  that  he  would  have  a 
return  of  his  haemorrhoids.  The  frequent  discharge  and 
staining  of  his  linen  gave  him  great  concern,  and  worried 
him  to  a  degree  which  seemed  almost  absurd,  and  quite  dis- 
proportioned  to  the  gravity  of  his  case.  This  I  have  often 
observed  in  persons  of  refined  feelings.  In  hospital  practice 
patients  do  not  often  complain  of  a  discharge  unless  it  be 
very  copious  or  accompanied  by  pain.  On  a  careful  exami- 
nation of  this  gentleuian  I  detected,  just  at  the  verge  of  the 
anus,  and  hidden  by  a  small  tab  of  skin,  a  minute  orifice;  a 
fine  probe  passed  into  this  and  through  a  short  sinus,  not 
quite  three-  quarters  of  an  inch  in  length,  into  the  bowel. 
From  the  history  of  the  case  (there  having  been  always  the 
same  purulent  discharge),  I  had  no  doubt  that  this  slight  fis- 


112  COMPLICATIONS    OF    HAEMORRHOIDS. 

tula  had  existed  in  conjunction  with  the  haemorrhoids,  but 
the  major  malady  had  masked  the  minor  one.  I  laid  open 
this  sinus,  and  in  a  week  the  patient  was  quite  well  and 
relieved  from  his  annoying  discharge. 

When  examining  a  case  of  haemorrhoids,  never  omit  to  pass 
the  finger  well  into  the  bowel,  to  ascertain  that  no  stricture, 
ulceration,,  or  malignant  disease  is  present.  I  have  made 
the  same  remark  before,  but  I  do  not  mind  repeating  it;  as  I 
have  so  often  seen  this  grave  error  committed.  It  has  many 
times  occurred  to  me  to  find  that  patients  have  been  operated 
upon  in  metropolitan  hospitals,  by  eminent  surgeons,  for 
piles,  when  they  were  suffering  at  the  same  time  from  can- 
cer or  ulceration  of  the  bowel.  I  need  scarcely  say  that  an 
operation  under  such  conditions  cannot  be  of  any  benefit  to 
the  patient. 

A  healthy-looking  young  man,  set,  28,  came  into  my  con- 
sulting room  quite  recently,  sent  to  me  as  a  case  of  piles  for 
operation  ;  a  few  questions,  however,  satisfied  me  that  there 
was  something  besides  the  piles.  An  examination  revealed 
carcinoma  high  up  the  rectum,  the  lower  margin  not  being 
nearer  than  three  inches  from  the  anus.  The  termination 
upward  could  not  be  reached,  but  by  using  my  ball-staff  I 
found  indications  of  contraction  and  great  hardness  at  the 
upper  part  of  the  rectum  or  commencement  of  the  sigmoid 
flexure. 

Impaction  or  accumulation  of  faeces  in  the  rectum  or  colon 
is  another  complication  worthy  of  mention.  I  have  said  that, 
prior  to  operating  upon  piles,  the  bowels  ought  to  be  thor- 
oughly cleared  ;  this  precaution  is  too  often  neglected.  It 
is  remarkable  how  much  better  patients  do  when  the  portal 
system  has  been  unloaded  by  free  purgation  ;  and  unless 
there  be  some  care  exercised  in  this  matter  you  may  occasion 
yourself  a  good  deal  of  trouble,  to  say  nothing  of  the  suffer- 
ing of  your  patient.  For  my  own  part,  I  am  tolerably  cer- 
tain that,  in  the  majority  of  those  cases  where  the  healing 
process  does  not  go  on  kindly,  a  loaded  colon  and  congested 
liver  are  the  chief  cause.  I  saw  with  a  professional  friend  a 
lady  upon  whom  he  had  operated  for  slight  internal  haemor- 
rhoids, and  in  whom  unhealthy  ulceration  had  followed. 
Prior  to  the  operation  the  patient  was  not  in  bad  health,  and 
might  reasonably  have  been  expected  to  do  well. 

Before  examining  the  rectum  I  inquired  as  to  the  state  of 
the  bowels  for  some  time  past,  and  from  the  account  given  I 
was  quite  satisfied  that  there  had  not  been  a  good  clearance 


COMPLICATIONS    OF    HAEMORRHOIDS.  II3 

effected.  Moreover,  although  action  had  taken  place  since 
the  operation,  there  had  been  only  scanty  relief,  and  when 
the  patient  got  out  of  bed  and  stood  up,  she  experienced 
inclination  to  go  to  stool,  and  abortive  straining  on  doing  so. 
On  introducing  my  finger  into  the  bowel  I  found  it  quite 
blocked  up  by  hardened  faeces.  This  impaction  was  got  rid 
of  by  manipulation  and  enemata;  then  aperients  were  given 
by  the  mouth,  and  a  large  quantity  of  lumpy  faeces  was 
evacuated.  When  I  saw  this  patient  again,  in  about  ten  days, 
the  ulceration  was  nearly  healed. 

I  operated  for  haemorrhoids  upon  a  young  gentleman  whose 
bowels,  he  said,  generally  acted  fairly,  and  had  done  so  freely 
before  the  operation;  but  at  the  end  of  a  week  he  complained 
of  abdominal  pains  and  desire  to  go  to  stool,  without  having 
a  satisfactory  evacuation;  this  led  me  to  examine  his  abdo- 
men, and  I  found  his  colon  quite  dull  on  percussion,  nearly 
throughout  its  course.  A  brisk  purge  administered  daily,  for 
three  days,  and  followed  by  enemata,  produced  most  copious 
action,  and  soon  improved  his  general  condition,  and  hastened 
the  healing  of  the  wounds. 

Another  marked  instance  of  this  complication  occurred  in 
a  lady  recommended  to  me  by  my  late  friend  Dr.  Daldy. 
She  was  a  delicate  person,  who  had  long  suffered  from  the 
frequent  combination  of  uterine  and  rectal  disorder.  She 
had  a  considerable  and  painful  prolapsus  of  the  bowel  when 
she  came  under  my  care,  her  uterine  malady  having  been 
previously  greatly  ameliorated,  if  not  cured.  The  bowels 
acted  daily  and,  according  to  her  statement,  sufficiently.  She 
had  the  usual  aperient  administered,  and  also  an  enema 
prior  to  the  operation,  with  good  effect;  but  about  the  time 
of  the  separation  of  the  ligatures  she  was  seized  with  severe 
abdominal  pains  and  straining,  and  on  examination  I  found 
the  rectum  blocked  up  by  hard,  dry,  friable  lumps  of  faeces, 
which  were  with  very  great  difficulty  got  rid  of ;  after  this 
aloetic  aperients  procured  the  evacuation  of  a  really  enor- 
mous collection  of  faeces;  it  seemed  as  if  the  whole  colon 
had  been  fully  charged.  All  this  delayed  her  recovery,  and 
caused  a  great  deal  of  pain,  but  eventually  she  got  well. 

Polypus  is  sometimes  found  in  conjunction  with  haemor- 
rhoids. I  operated  some  time  back  on  the  wife  of  a  well- 
known  physician,  who,  in  addition  to  haemorrhoids,  had  a 
large-sized,  hard,  pedunculated  polypus. 

My  colleague,  Mr.  Goodsall,  assisted  me  once  in  operat- 
ing upon  a  lady  who   had  a  fissure,  polypus,  and  hsemor- 


114      HiEMORRHAGE    AFTER   OPERATIONS   UPON    PILES. 

rhoids;  her  sufferings  had  really  been  very  great,  and  she  had 
lost  much  blood.  In  these  cases  a  ligature  must  be  placed 
upon  the  polypus  as  well  as  the  piles.  A  gentleman  with 
fissure,  haemorrhoids,  and  a  very  large  fibrous  polypus,  with 
a  hard  peduncle,  was  recently  introduced  to  me  by  my 
friend,  Dr.  Wm.  Henry  Stone,  of  St.  Thomas's  Hospital. 
This  condition,  by  the  patient's  history,  had  clearly  exis- 
ted for  years,  and  caused  him  great  pain  when  the  growth 
came  outside  the  anus,  as  it  frequently  did  at  stool.  This 
gentleman  had  been  operated  on  twelve  years  before  my  see- 
ing him,  a  small  polypus  being  then  removed. 


CHAPTER  XI. 

HAEMORRHAGE    AFTER   OPERATIONS    UPON    PILES. 

This  will  occasionally  take  place,  and  it  may  be  either 
accidental,  recurrent,  or  secondary. 

Just  as  in  midwifery  you  may  go  on  for  years  without  the 
occurrence  of  an  untoward  event,  and  then  get  a  batch  of 
troublesome  cases,  so  it  is  in  this  operation;  you  may  per- 
form it  a  large  number  of  times  without  the  slightest 
unpleasant  symptom  resulting,  and  then  have  a  run  of  cases 
which  cause  you  more  or  less  anxiety. 

If  the  operation  be  carefully  done,  primary  haemorrhage  is 
very  rare;  occasionally,  when  large  and  very  vascular 
haemorrhoids  are  ligatured,  and  there  is  also  much  super- 
abundant skin  cut  away,  a  small  vessel  will  bleed  when  the 
patient  recovers  from  the  shock;  this  is  a  trivial  matter,  and 
a  ligature  is  easily  applied.  I  think  it  will  scarcely  ever 
occur  if  the  precaution  of  putting  on  a  good  pad  of  wool  and 
a  T-bandage  is  adopted.  Now  and  then,  particularly  if  the 
patient  has  been  unruly  under  the  operation,  the  ligature 
may  not  have  been  placed  quite  at  the  bottom  of  the  incis- 
ion, and  some  bleeding  may  then  result.  The  ready  way  to 
arrest  this  is  to  draw  down  the  bowel  by  the  ligatures,  the 
patient  assisting  you  by  straining;  you  will  then,  in  all  proba- 
bility, be  able  to  see  the  bleeding  vessel  and  tie  it.  If  you 
do  not  see  it,  or  if  a  general  oozing  is  apparent,  pass  all  the 
ligatures  through  a  hole  made  in  the  middle  of  a  small, 


t 

HAEMORRHAGE    AFTER   OPERATIONS   UPON   PILES.       II5 

round  sponge,  then  tie  them  across  a  piece  of  stick,  and 
twist  this  round.  In  this  way  you  construct  a  sort  of  tour- 
niquet, and  can  make  firm  and  strong  pressure  with  the 
sponge,  so  that  no  bleeding  can  take  place.  In  a  few  hours 
after  it  is  all  arrested  the  stick  may  be  removed. 

In  the  old  plan  of  operating  with  a  double  ligature  and 
transfixion  of  the  base  of  the  haemorrhoid,  bleeding  used 
from  time  to  time  to  occur  from  perforation  of  a  vessel — 
usually  a  vein — by  the  needle.  When  this  takes  place,  on 
the  ligatures  being  tied,  the  vessel  would  be  more  or  less 
torn  open,  and  bleeding  would  ensue  at  the  time,  or  shortly 
afterwards. 

I  have  more  than  once  been  called  to  see  a  patient  to 
whom  this  accident  had  occurred.  It  is  easily  remedied  by 
drawing  down  the  piles  by  the  ligatures,  and  placing  one 
ligature  above  the  spot  where  the  bleeding  haemorrhoid  was 
transfixed. 

In  cases  of  sloughing  haemorrhoids  the  parts  are  some- 
times so  much  disintegrated  that  very  free  haemorrhage 
takes  place  ;  at  the  same  time  a  ligature  is  not  easily 
applied,  in  consequence  of  the  tissues  readily  breaking 
down. 

I  once  had  a  rather  startling  accident  occur  after  operat- 
ing. A  gentleman  came  up  from  the  country,  and 
was  operated  upon  by  me  for  piles;  it  was  a  bad 
case,  and  five  ligatures  were  applied.  The  night  fol- 
lowing the  operation  he  was  attacked  quite  sud- 
denly with  delirium  tremens,  and  in  a  paroxysm  of 
mania  tore  off  three  of  the  ligatures.  The  loss  of  blood  was 
very  considerable.  When  I  arrived  at  the  house  I  found 
the  patient,  the  bed,  and  the  floor  of  the  room  covered  with 
blood.  I  had  much  difficulty  in  placing  ligatures  on  the 
bleeding  vessels,  as  the  patient,  although  very  collapsed,  was 
capable  of  offering  resistance.  Curiously  enough,  he  did 
exceedingly  well  afterwards;  I  do  not  think  that  the  acci- 
dent delayed  his  recovery  a  single  day.  He  had  not  been  an 
habitual  drunkard,  but  the  fear  of  the  operation  induced 
him,  for  about  a  week  before  he  came  up  to  undergo  it,  to 
drink  quantities  of  champagne  and  brandy;  this,  with  the 
chloroform  and  the  shock  of  the  operation,  brought  on 
acute  delirium. 

Another  case  of  accidental  haemorrhage  occurred  to  a 
patient  of  my  friend  Mr.  Blackman,  of  Highbury.  I 
operated   for  him    upon  an  elderly  gentleman  who  had  a 


Il6       HAEMORRHAGE    AFTER    OPERATIONS    UPON    PILES. 

very  large  hsemorrhoid,  which  had  undergone  fibroid 
degeneration;  it  was  situated  dorsally,  was  as  large  as  a 
hen's  egg,  and  always  came  down  at  stool,  giving  a  great 
deal  of  trouble.  Ulceration  had  taken  place  at  the  upper 
part  of  the  pile.  I  placed  a  ligature  upon  it,  and  then  cut 
the  tumor  off.  At  the  time  of  tightening  the  ligature  I  felt 
that  the  tissues  were  very  friable,  and  I  examined  the  site  of 
the  ligature  to  see  if  it  had  cut  through  much,  but  could  not 
discover  that  it  had  done  so,  and  there  was  no  bleeding. 
When  I  saw  the  patient  in  the  morning,  with  Mr.  Blackman, 
we  found  that  considerable  haemorrhage  had  taken  place 
since  4  a  m.,  the  cause  being  probably  as  follows:  He  had 
not  passed  any  water,  and  feeling  a  very  urgent  desire,  he 
jumped  quickly  out  of  bed,  and  strained  violently  to  empty 
his  bladder;  at  the  time  he  was  doing  this  he  felt  something 
give  way  in  the  rectum,  and  on  getting  back  into  bed  his 
wife  observed  that  he  was  bleeding.  I  forcibly  dilated  his 
sphincter,  and  then  with  a  volsellum  drew  down  the  bowel, 
and  placed  another  ligature  above  the  first  one.  This  at 
once  arrested  the  bleeding,  but  the  next  day  but  one  it 
recurred  to  an  alarming  extent,  and  I  found  the  parts  so 
soft  and  sloughy  that  no  ligature  would  hold;  under  these 
circumstances  I  plugged  the  rectum  (in  the  manner  I  will 
presently  describe).  This  plug  was  retained  for  about  ten 
days,  and  he  had  no  more  haemorrhage,  and  eventually  did 
well,  although  for  some  time  he  gave  Mr.  Blackman  and 
myself  no  little  anxiety. 

I  will  relate  one  more  case.  In  the  year  1866  I  operated 
at  St.  Mark's  with  the  clamp  and  cautery,  upon  a  really 
severe  case  of  internal  haemorrhoids.  The  parts  were  very 
vascular,  and  I  had  considerable  difficulty  in  controlling  the 
haemorrhage,  having  to  apply  the  cautery  a  good  many  times. 
When  the  patient  left  the  operating  table  there  was  no 
bleeding  at  all;  but  in  the  evening  I  was  sent  for  by  the 
house-surgeon,  as  very  free  arterial  haemorrhage  had  come 
on.  The  patient  was  very  timid  and  the  parts  very  tender, 
so  that  I  had  much  trouble  to  introduce  a  speculum;  and 
when  I  did  I  could  not  find  the  spot  whence  the  blood  came. 
I  ordered  the  injection  of  ice  water  and  perchloride  of  iron; 
this  had  the  effect  of  arresting  the  flow,  but  only  tempor- 
arily. 

When  I  saw  the  patient,  early  in  the  morning,  I  was  told 
that  he  had  lost  a  good  deal  of  blood  during  the  night,  and 
the  flux  was  still  going  on,  so  I  determined  to  find  the  ves- 


HEMORRHAGE    AFTER    OPERATIONS    UPON    PILES.       II7 

sel,  if  it  were  possible.  Accordingly  I  passed  my  finger  into 
the  bowel,  and  on  that  I  guided  a  volsellum,  and  catching  a 
good  hold  of  the  rectum,  I  pulled  that  part  down;  while  that 
was  held  I  used  another  volsellum  on  the  other  side  of  the 
bowel,  and  thus  succeeded  in  bringing  the  inside  of  the  rec- 
tum well  into  view.  This  done,  I  found  two  points  from 
which  the  blood  escaped  in  jets,  so  I  placed  ligatures  upon 
these  vessels,  and  the  haemorrhage  was  arrested. 

I  leave  the  reader  to  imagine  how  much  pain  the  patient 
must  have  suffered  from  this  proceeding.  He  had  such  a 
tendency  to  faint  that  I  was  afraid  to  give  him  chloroform. 
Ether  was  not  then  in  vogue. 

These  cases  may,  I  think,  be  correctly  styled  accidental 
or  recurrent  haemorrhage.  Of  late  years  I  have  had  this 
form  of  hemorrhage  occur  much  less  frequently.  As  a  rule, 
I  should  say  what  we  have  most  to  fear  is  secondary  haemor- 
rhage, which  usually  comes  on  at  or  about  the  time  of  the 
separation  of  the  ligatures.  This  form  of  bleeding  occurs 
generally  in  elderly  people  of  broken-down  constitutions,  or 
in  those  who  have  been  very  free  livers.  I  may  say,  as  far 
as  my  experience  goes,  that  this  haemorrhage  is  usually  more 
venous  than  arterial.  Of  course  there  are  exceptions  to  the 
rule  of  its  occurrence  in  elderly  people.     Here  is  one: — 

A  gentleman,  aet.  23,  had  all  his  life  suffered  from  rectal 
disease;  when  a  child  from  procidentia,  and  by  the  time  he 
was  eighteen  from  bleeding  haemorrhoids.  When  I  saw  him 
he  had  a  prolapse  of  the  lower  part  of  one  side  of  the  rec- 
tum, which  came  down  on  very  slight  exertion;  he  was  very 
thin  and  weak,  and  subject  to  fainting.  I  put  two  ligatures 
upon  his  prolapsus,  assisted  by  my  colleague  Mr.  Goodsall. 
Mr.  Buxton  Shillitoe  administered  the  chloroform,  with  his 
usual  care  and  discrimination,  and  although  very  little  was 
given,  and  the  operation  did  not  take  one  minute  to  per- 
form, the  patient  fainted,  and  we  had  considerable  trouble 
in  recovering  him.  I  was  quite  convinced  that  had  the 
chloroform  been  given  recklessly  or  unskillfully  death  would 
have  ensued. 

This  gentleman  went  on  very  well  indeed  until  the  sixth 
day,  when  the  ligatures  came  away  on  the  bowels  acting. 
Soon  after  this — he  had  returned  to  his  bed — he  said  he  felt 
faint,  then  that  he  wanted  to  go  to  stool;  and  on  being 
assisted  up  to  do  so,  he  nearly  filled  the  pan  with  dark 
blood,  and  fainted  away.  I  was  sent  for  in  great  haste,  and 
directly  saw  that  he  had  lost  and  was  still  losing  a  large 


Il8       Hi¥:MORRHAGE    AFTER    OPERATIONS    UPON    PILES. 

quantity  of  blood.  This  was  not  a  case  in  which  one  could 
afford  to  temporize,  so  I  at  once  plugged  his  bowel  with  cot- 
ton wool  and  subsulphate  of  iron,  which  I  had  with  me.  I 
was  quite  sure  that  it  was  no  use  to  search  for  the  bleeding 
vessel  or  vessels.  The  plugging  immediately  arrested  the 
haemorrhage,  and  I  kept  the  wool  in  for  ten  days;  I  then 
carefully  removed  it,  and  no  further  bleeding  took  place. 
The  patient  soon  got  quite  well.  This  is  the  only  case  of 
severe  secondary  haemorrhage  I  ever  had  in  a  young  person. 

An  elderly  gentleman  came  from  the  country  to  be  under 
my  care.  He  had  been  much  in  hot  climates,  had  led  rather 
a  dissipated  life,  and  worked  very  hard.  He  was  only  fifty- 
four,  but  he  looked  sixty-five  at  least.  He  suffered  from  a 
constantly  prolapsed  hsemorrhoid.  I  saw  no  reason  why  it 
should  not  be  removed;  accordingly  I  applied  a  ligature  in 
my  usual  way.  The  patient  did  capitally  until  the  fifth  day, 
when  the  ligature  came  away  on  his  going  to  stool.  I  saw 
him  in  the  afternoon  and  he  was  very  comfortable,  and 
said  he  should  get  up  and  lie  on  the  sofa.  I  made  no 
objection,  and  he  did  so. 

At  night,  I  was  summoned  hastily,  as  he  was  bleeding; 
when  I  arrived  I  found  him  quite  collapsed,  and  the  blood 
was  literally  pouring  out  from  his  rectum.  The  haemorrhage 
had  come  on  suddenly  when  he  was  moving  from  his  sofa 
in  the  sitting-room  to  the  bedroom  on  the  same  floor,  I 
plugged  instantly  and  arrested  the  bleeding;  he  suffered  a 
good  deal  of  distress  from  flatulence,  and  I  was  compelled 
to  remove  the  sponge  on  the  sixth  day.  To  my  intense 
annoyance,  after  twenty-four  hours,  the  haemorrhage  recur- 
red quite  as  badly  as  at  first.  I  was  thus  obliged  to  re-plug  the 
rectum,  but  this  time,  not  wishing  to  remove  the  plug  early, 
I  adopted  the  precaution  of  introducing  a  full-sized  elastic 
catherer  at  the  side  of  the  wool,  so  that  he  was  able  to  get 
rid  of  flatus  through  it.  This  was  all  retained  for  nineteen 
days,  when  I  gradually  and  carefully  drew  the  plugging  out; 
there  was  no  turther  bleeding.  I  am  free  to  confess  that 
this  case  caused  me  much  anxiety. 

A  man,  aet,  62,  was  operated  upon  by  me  at  St.  Mark's 
Hospital,  in  July,  1868.  He  was  a  feeble  man,  and  had  no 
power  in  his  sphincter  muscles.  He  suffered  from  prolapsed 
haemorrhoids,  which  were  always  down.  I  used  the  clamp 
and  cautery. 

On  the  fourth  day  hemorrhage  commenced  after  action  of 
the  bowels;    at  first  the  blood  was  small  in  quantity,  and 


HEMORRHAGE    AFTER    OPERATIONS    UPON    PILES.       II9 

passed  only  when  he  moved  or  coughed;  it  came  away  fluid, 
and  also  in  small  clots;  it  was  venous  in  character.  Ice 
water  with  perchloride  of  iron  was  injected,  but  failed  to 
arrest  it.  When  I  saw  him  he  was  very  pale  and  faint,  and 
the  haemorrhage  was  nearly  constant,  the  blood  slowly  trick- 
ling out  of  the  anus.  On  examination  I  found  the  bowel 
full  of  blood.  I  plugged  the  rectum  fully,  with  cotton  wool, 
into  which  was  dusted  the  sub-sulphate  of  iron;  this  at  once 
stopped  the  bleeding.  The  plug  was  retained  for  six  days, 
and  when  it  was  removed  there  was  no  return  of  haemor- 
rhage. This  patient  was  very  weak  and  ill  for  some  time, 
and  he  suffered  from  an  attack  of  purpura.  He  rallied, 
however,  under  good  diet  and  stimulants,  and  left  the  hospi- 
tal quite  recovered. 

When  bleeding  is  taking  place  internally  and  in  conse- 
quence of  tightness  of  the  sphincter  the  blood  does  not 
escape;  the  patient  will  always  tell  you  "  that  he  feels  some- 
thing running  inside  the  bowel,"  and  this  may  continue 
until  the  rectum  (and  even  the  sigmoid  flexure)  is  full  of 
clots  and  fluid  blood.  If  you  suspect  this,  and  pass  your 
finger  into  the  anus,  you  will  excite  contraction  of  the  gut, 
and  the  contents  will  then  be  expelled  with  more  or  less 
force.  The  trickling  sensation  I  always  take  as  a  pretty  cer- 
tain indication  of  internal  bleeding,  and  I  act  accordingly. 
If  you  dilate  the  sphincters  prior  to  operating,  this  retention 
of  blood  in  the  bowel  is  not  likely  to  take  place,  as  there 
can  be  no  contraction  of  the  orifice  of  the  anus.  This  is 
another  advantage  resulting  from  dilatation.  These  cases 
do  very  well  if  prompt  and  judicious  treatment  be  adopted. 
I  have  never  lost  a  patient,  although  I  have  seen  persons  in 
considerable  danger.  If  the  bleeding  were  allowed  to  con- 
tinue long,  I  have  not  the  slightest  doubt  that  a  fatal  issue 
would  be  the  result;  so  I  will  in  some  detail  describe  the 
method  of  treatment  I  consider  most  advisable. 

I  have  found  it  utterly  futile,  in  cases  of  secondary  haem- 
orrhage, to  try  and  place  a  ligature  round  the  vessels;  it  is 
usually  the  large  veins  or  venous  sinuses  which  are  opened 
by  sloughing  or  ulceration,  and  when  you  introduce  a  specu- 
lum and  try  to  find  the  source  of  bleeding,  you  can  only  see 
that  the  whole  rectum  is  filled  with  blood,  and  on  passing 
your  finger  you  will  feel  a  quantity  of  clots. 

When  called  to  cases  of  severe  haemorrhage,  always  arm 
yourself  with  a  full-sized,  bell-shaped  sponge  and  plenty  of 
cotton  wadding;  take  also  some  subsulphate  of  iron,  or  if 


I20      HAEMORRHAGE    AFTER    OPERATIONS    UPON    PILES.. 

you  have  not  that,  powdered  alum  or  tannin.  Pass  a  strong 
silk  ligature  through,  near  the  apex  of  your  cone-shaped 
sponge,  and  bring  it  back  again,  so  that  the  apex  of  the 
sponge  is  held  in  a  loop  of  the  thread.  Then  wet  the  sponge, 
squeeze  it  dry,  and  powder  it  well,  filling  up  the  lacunae  with 
the  iron  or  other  astringent.  Pass  the  fore-finger  of  your 
left  hand  into  the  bowel,  and  upon  that  as  a  guide  push  up 
the  sponge — apex  first — by  means  of  a  metal  rod,  bougie, 
pen-holder,  or  a  rounded  piece  of  wood,  if  you  can  get 
nothing  better.  Now,  this  sponge  should  be  carried  up  the 
bowel  at  least  five  inches,  the  double  thread  hanging  outside 
the  anus.  AVhen  this  is  so  placed  fill  up  the  whole  of  the 
rectum  below  the  sponge  thoroughly  and  carefully  with 
cotton  wool  well  powdered  with  the  alum  or  iron.  When 
you  have  completely  stuffed  the  bowel,  take  hold  of  the  silk 
ligature  attached  to  the  sponge,  and  while  with  one  hand  you 
pull  down  the  sponge,  with  the  other  hand  push  up  the  wool. 
This  joint  action  will  spread  out  the  bell  shaped  sponge,  like 
opening  an  umbrella,  and  bring  the  wool  compactly  together; 
if  this  be  carefully  done  no  bleeding  can  possibly  take  place, 
either  internally  or  externally.  Half  measures  in  these  cases 
are  worse  than  useless,  as  valuable  time  is  thereby  lost.  This 
plug  should  remain  in  at  least  a  week,  and  it  may  be  retained 
a  fortnight  or  more.  It  may  be  thought  that  much  straining 
and  pain  would  be  caused  by  it.  I  assure  you  this  is  not  the 
case;  if  you  keep  your  patients  fairly  under  the  influence  of 
opium  they  very  rarely  complain.  The  only  trouble  may  be 
wind,  and  this  often  will  find  its  own  way  out.  If  you  fear 
this,  and  have  a  male  catheter  or  flexible  tube  handy,  you 
may  introduce  it  through  the  centre  or  by  the  side  of  the 
sponge,  packing  the  wool  around  it.  I  have  done  this  several 
times,  and  found  the  patients  passed  not  only  wind  through 
it,  but  also  broken-down  blood  and  liquid  faeces.  I  am  sure 
you  need  never  fear  a  case  of  haemorrhage  if  you  only  plug 
methodically  and  thoroughly.  I  think  very  highly  of  the 
subsulphate  of  iron;  no  styptic,  in  my  opinion,  answers  as 
well.  It  is  far  superior  to  the  perchloride,  as  it  does  not 
cause  burning  or  pain.  In  slight  cases  of  bleeding  the  injec- 
tion of  a  strong  solution  of  tannin,  or  even  ice  water,  keeping 
a  lump  of  ice  on  the  sacrum,  and  the  patient  cool  and  quiet, 
may  be  suflicient,  but  I  say  never  leave  a  patient  who  has  at 
all  continuous  or  free  haemorrhage  without  the  plug. 

Practitioners  who  are  not  frequently  operating  on  haemor- 
rhoids cannot  be  expected  to  possess  all  the  most  modern 


ttiSMORRHAGEl    AFTER    OPERATIONS    UPON    PILES.       l2l 

appliances,  but  I  can  recommend  my  friend  Mr.  Gowlland*3 
tubes,  which  are  made  of  vulcanite,  shaped  like  a  bougie, 
seven  inches  in  length  and  about  one  inch  in  diameter;  the 
base  terminates  in  a  rim,  which  is  perforated, 'so  that  it  can 
be  sewn  to  a  bandage,  I  have  had  tubes  made  with  holes 
two  inches  from  the  apex,  so  that  sponge  can  be  sewn  on 
around  them.  When  this  is  passed  up  the  rectum  you  pack 
wool  all  around  it.  The  advantages  are  obvious;  flatus, 
liquid  faeces,  and  broken-down  blood  can  pass;  you  can  also 
inject  frequently  a  weak  solution  of  Condy's  fluid,  which 
will  keep  the  part  clean  and  sweet;  do  not  use  carbolic  acid 
as  it  frequently  gives  rise  to  much  irritation. 

The  after-treatment  of  these  cases  requires  considerable 
care  and  attention  to  details;  generally  the  patient  is  very 
greatly  alarmed  at  the  bleeding,  but  his  fears  wnll  be  soon 
allayed  if  he  finds  you  are  prompt  and  confident  of  your 
own  powers  to  succor  him.  After  the  haemorrhage  is 
arrested  by  the  plugging,  the  recumbent  position  must  be 
maintained,  and  on  no  account  whatever  should  an  upright 
posture  be  assumed.  If  the  packing  be  tight,  frequently 
retention  of  urine  will  occur,  and  you  must  pass  a  catheter; 
but  you  should,  if  possible,  at  once  teach  the  patient  to 
introduce  the  instrument  for  himself,  A  Mercier's  flexible 
coudee  catheter  goes  so  readily  into  the  bladder  that  any 
but  the  most  timid  person  may  in  one  lesson  acquire  the 
art.  The  buttocks  and  lower  part  of  the  back  should  be 
kept  cool,  I  employ  dry  cold,  by  means  of  ice  in  an  india- 
rubber  bag,  applied  to  the  sacrum.  If  the  patient  is  exceed- 
ingly collapsed  do  not  apply  cold.  I  have  found  hot  sponges 
to  the  sacrum  advantageous.  Stimulants  may  be  given,  but 
it  is  better,  if  possible,  to  wait  for  some  hours  and  observe 
what  amount  of  reaction  takes  place;  this  is  sometimes  con- 
siderable, and  will  make  you  wish  that  you  had  withheld 
alcohol  or  used  it  very  sparingly.  As  soon  as  it  can  be 
taken,  nourishment  is  to  be  given,  and  Liebig's  cold  soup, 
which  can  be  quickly  prepared,  I  have  found  a  wonderful 
restorative.*  Hot  liquids,  I  need  scarcely  say,  are  to  be 
avoided.  I  do  not  think  it  necssary  to  keep  these  patients 
entirely  on  fluid  diet;  directly  they  can  take  solid  food  let 
them  have  it,  but  it  should  be  nourishing  and  easy  of  diges- 

*  Liebig's  cold  soup  is  prepared  thus:  Take  8  oz.  of  raw,  lean  beef, 
finely  minced,  put  it  into  20  oz.  of  cold  water,  add  10  drops  of  strong 
hydrochloric  acid  and  a  little  salt  ;  let  it  stand  half  an  hour  and  then 
strain.     One  or  two  ounces  may  be  given  every  half  hour. 


122  iPROCIDENTIA    RECTI. 

tion.  As  secondary  hgemorrhage  generally  occurs  in  persons 
whose  blood  and  tissues  are  deficient  in  plastic  material,  the 
aim  of  treatment  must  be  to  remedy  that  defect,  and 
thoroughly  nutritious  food  judiciously  administered  is,  I 
imagine,  the  most  valuable  means  to  that  end. 

I  do  not  place  much  trust  in  the  internal  use  of  astringent 
remedies.  The  hypodermic  injection  of  ergotine  I  shall  use 
when  I  have  a  case  that  I  consider  not  very  urgent,  but  I 
always  prescribe  iron,  not  only  as  a  haemostatic,  but  also  for 
its  blood-repairing' property.  I  prefer  either  the  Tinct. 
Ferri  Perchloridi,  or  the  Liq.  Ferri  Peracetatis.  If  the 
stomach  bears  this  well,  full  doses  may  be  given  twice  or 
thrice  in  the  day;  in  addition,  a  pill  containing  one  grain 
of  solid  opium,  night  and  morning,  or  at  night  only,  if  the 
bowels  do  not  exhibit  any  tendency  to  act  and  there  is  no 
straining,  will  generally  meet  the  requirements  of  the  case. 


CHAPTER  XII. 

PROCIDENTIA     RECTI. 

There  is  sometimes  a  confusion  of  ideas  occasioned  by  the 
use  of  the  words  procidentia  and  prolapsus. 

Internal  hsemorrhoids,when  they  have  come  down  outside 
the  anus,  are  said  to  be  prolapsed,  and  the  case  if  frequently 
called  prolapsus  ani  ;  but  there  is  a  very  marked  pathologi- 
cal distinction  to  be  observed  between  prolapsed  haemorrhoids 
and  prolapsus  of  the  rectum. 

Prolapsus  is  a  descent  of  the  lowest  part  of  the  rectum, 
the  mucus  membrane  and  sub-mucous  tissue,  both  occasion- 
ally thickened,  being  turned  out  of  the  anus.  Now,  this 
condition  differs  from  prolapsed  haemorrhoids  thus:  The 
haemorrhoids  exist  as  separate  and  distinct  rounded  tumors, 
while  the  prolapsus  may  be  seen  to  surround  the  anus  with- 
out any  division  into  definite  tumors,  only  the  natural  folds 
of  the  bowels  being  observed;  generally  there  is  one  distinct 
fold  towards  the  perineum,and  the  remainder  forms  a  horse- 
shoe-shaped projection  around  the  sides  and  back  part  of 
the  anus.      The  appearance   and  touch   also  of   prolapsus 


PROCIDENTIA    RECTI.  1 23 

differ  from  piles  in  its  not  being   smooth,  hard,   and  shiny, 
but  soft  and  velvety. 

If  you  thought  fit,  you  would  operate  upon  such  a  case  in 
the  same  manner  as  you  would  upon  internal  haemorrhoids, 
with  this  exception,  that  the  larger  segment  of  the  rectum 
will  require  to  be  divided  vertically  into  two  or  three  por- 
tions,in  order  that  several  ligatures  may  be  applied,  to  ensure 
a  complete  strangulation  of  the  part. 

True  procidentia  is  the  decent  of  the  upper  part  of  the 
rectum,  in  its  whole  thickness,  or  all  its  coats,  through  the 
anus. 

There  is  a  variety  of  procidentia  which  one  may  call  intus- 
susception, the  upper  part  of  the  rectum  descending  through 
tha  lower  part;  this  is  diagnosed  from  ordinary  procidentia 
by  there  being  a  more  or  less  deep  sulcus  around  the  inner 
column  of  the  intestine,  so  that  there  are,  as  it  were,  two 
cylinders  of  rectum,  one  inside  the  other.  This  condition 
is  often  associated  with,  and  caused  by,  the  growth  of  a  poly- 
pus; it  givet  rise  to  a  train  of  very  distressing  symptoms, 
which  may  continue  long  after  the  removal  of  the  growth 
which  has  been  the  starting  point  of  the  malady.  I  had  a 
a  lady  under  my  care,  sent  to  me  by  Dr.  Gervis,  who  some 
time  before  had  a  rectal  polypus  removed,  but  she  still  had 
great  suffering;  a  sensation  of  burning  and  fullness  in  the 
bowel  attended  with  tenesmus  and  difficulty  in  defecation. 
She  has  an  intussusception  of  the  upper  part  of  the  rectum 
into  the  middle  and  lower  part;  the  bowel  does  not  gener- 
ally come  outside  the  anus,  but  approaches,  when  she  strains, 
near  to  it.  I  have  seen  many  cases  of  this  kind.  One  very 
troublesome  case,  a  middle-aged  single  lady,  sent  me  by  Dr. 
J.  Grey  Glover,  had  an  intussusception  and  constipation, 
with  constant  straining;  she  suffered  greatly,  and  took  all 
kinds  of  aperients  and  other  medicines.  At  last  she  regained 
much  comfort  by  following  out  my  suggestion — of  always 
having  action  of  the  bowels  lying  down,  and  keeping  recum- 
bent for  an  hour  or  so  afterward.  The  worse  thing  that  cah 
be  done  for  these  patients,  is  to  give  way  to  their  craving  for 
purgatives. 

Sometimes  a  procidentia  occurs  conjointly  with  internal 
haemorrhoids;  in  this  case,  when  the  procidented  gut  is 
gently  returned,  there  still  remains  outside  of  the  anus  a  ring 
of  haemorrhoids,  or  loose  and  thickened  mucous  membrane; 
and  I  may  mention  that  these  cases  are  the  most  satisfactory 
to  treat,  as  ligature  of  the  haemorrhoids,  will  almost  certainly 


124  PROCIDENTIA    RECTI. 

cure  the  procidentia.     This  was  clearly    shown  by  the   late 
Mr.  Hey,  of  Leeds. 

Procidentia  of  the  rectum  is  more  often  seen  in  children 
than  adults,  although  it  is  by  no  means  a  rare  affection  in 
women — particularly  those  who  have  borne  many  children 
— and  in  men  in  advanced  years.  Procidentia  in  children 
is  much  favored  by  the  formation  of  the  pelvis,  the  sacrum 
being  nearly  straight.  Moreover,  all  infants  strain  violently 
when  their  bowels  act,  even  when  their  motions  are  quite 
soft.  There  appears  to  be  some  physiological  necessity  for 
this,  which  I  do  not  pretend  to  explain  or  understand;  but 
these  facts  are  not  quite  sufficient  to  account  for  the  prone- 
ness  of  children  to  this  malady;  there  is  always,  in  addition, 
some  inherent  weakness  or  extraneous  source  of  irritation 
present,  by  which  excessive  straining  is  caused.  We  may 
mention  diarrhoea — often  the  result  of  strumous  inflammation 
of  the  intestines,  worms,  stone  in  the  bladder,  phimosis, 
polypus  recti,  etc.  There  are  many  cases,  however,  in  which 
we  can  assign  no  special  cause,  where  the  child  is  not  mani- 
festly unhealthy,  and  no  source  of  irritation  can  be  detected. 

I  am  sure  that  the  very  bad  custom  of  placing  a  child 
upon  the  chamber  utensil,  and  leaving  it  there  for  an  indefi- 
nite period,  as  practised  by  many  mothers  and  nurses,  is  a 
fertile  cause  of  procidentia. 

In  children  the  treatment  is  generally  successful;  it  should 
first  be  addressed  to  the  removal  of  any  source  of  irritation; 
this  accomplished,  a  cure  is  speedily  affected.  When  no 
source  of  itritation  can  be  discoved,  the  general  health  must 
be  attended  to.  The  child  should  never  be  allowed  to  sit 
and  strain  at  stool;  the  motion  should  be  passed  lying  upon 
the  side,  at  the  edge  of  the  bed,  or  in  a  standing  position, 
and  one  buttock  should  be  drawn  to  one  side,  so  as  to  tighten 
the  anal  orifice  which  the  faeces  are  passing;  this  device  I 
have  found  to  be  very  useful;  it  is  recommended  in  "  Druitt's 
Surgery,"  but  upon  whose  authority  I  do  not  know. 

When  the  bowels  have  acted,  the  protruded  part  ought  to  be 
well-sluiced  with  cold  water,  and  afterward  a  solution  of 
alum  and  oak  bark,  infusion  of  matico,  krameria,  or  weak 
carbolic  acid,  should  be  thoroughly  applied  with  a  sponge; 
the  bowel  must  then  be  returned  by  gentle  pressure,  and 
the  child  should  remain  recumbent  for  some  little  while, 
lying  upon  its  face  on  a  couch,  before  running  about.  If 
there  be  any  intestinal  irritation,  I  generally  order  small 
doses  of  Hydrarg.  cum  Creta,  with  rhubarb,  at  bedtime,  and 


PROCIDENTIA   RECTI.  1 25 

steel  wine  two  or  three  times  in  the  day.  When  the  child  is 
very  ill-nourished,  cod-liver  oil  does  much  good;  the  diet 
should  be  nourishing  and  digestible. 

If  these  mild  measures  do  not  succeed,  I  find  the  appli- 
cation of  strong  nitric  acid  the  best  remedy.  Chloroform 
should  be  given,  and  the  protruded  gut  well  dried.  The 
acid  must  be  applied  all  over  it,  care  being  taken  not  to 
touch  the  verge  of  the  anus  or  the  skin.  The  part  is  then 
to  be  oiled  and  returned,  and  the  rectum  stuffed  thoroughly 
with  wool ;  a  pad  must  after  this  be  applied  outside  the  anus, 
and  kept  firmly  in  position  by  strapping  plaster,  the  buttocks 
being  by  the  same  means  brought  closely  together;  if  this 
precaution  be  not  adopted,  when  the  child  recovers  from  the 
chloroform,  the  straining  being  urgent,  the  whole  plus;  will  be 
f'orced  out,  and  the  bowel  will  again  protrude.  When  the 
pad  is  properly  applied,  the  straining  soon  ceases,  and  the 
child  suffers  little  or  no  pain.  I  always  order  a  mixture  of 
aromatic  confection,  with  a  drop  or  so  of  tincture  of  opium, 
so  as  to  confine  the  bowels  for  four  days.  I  then  remove 
the  strapping  and  give  a  teaspoonful  of  castor  oil.  When 
the  bowels  act,  the  plug  comes  away,  and  there  is  no  descent 
of  the  rectum. 

I  have  had  experience  of  this  treatment  in  a  great  many 
cases;  I  never  knew  it  to  fail  if  properly  carried  out,  and 
only  on  two  occasions  have  I  had  to  apply  the  acid  more 
than  once.  The  result,  also,  is  not  a  temporary,  but  a  per- 
manent benefit. 

Procidentia  in  the  adult  is  a  very  much  more  unmanagea- 
ble affection,  and  is  supposed  in  many  instances  to  be  quite 
incurable. 

Numerous  operative  procedures  have  been  recommended 
for  the  cure  of  this  malady,  in  its  advanced  stages,  but  I 
cannot  say  I  am  satisfied  with  any  of  them,  save  one  to  be 
presently  described;  all  the  others  I  have  seen  fail.  The 
application  of  fuming  nitric  acid,  or,  what  I  think  prefera- 
ble, the  acid  nitrate  of  mercury,  often  does  much  good, 
although,  unfortunately,  the  relief  is  usually  only  tempo- 
rary; I  have  had  patients  to  whom  the  acid  has  been  fre- 
quently and  very  thoroughly  applied,  but  without  effecting 
a  cure.  The  use  of  the  acid  in  such  cases  is  not  at  all  pain- 
ful if  the  skin  be  not  touched;  it  causes  only  a  burning  sen- 
sation, which  soon  passes  off.  As  in  children,  the  gut 
should  be  oiled  before  returning  it,  and  the  bowels  should 
be  confined  for  a  few  days. 


126  PROCIDENTIA    RECTI. 

In  old  persons,  or  in  those  with  a  broken  down  constitu- 
tion, a  very  free  application  of  the  acid  is  to  be  deprecated, 
as  a  deep  slough  may  form,  some  vessel  be  opened  on  its 
separation,  and  severe  haemorrhage  take  place;  this  compli- 
cation occurred  to  me  at  St.  Mark's,  in  the  person  of  an 
elderly  woman  of  feeble  powers;  she  lost  very  much  blood, 
and  the  flux  was  arrested  only  by  plugging  the  rectum.  The 
same  observation  applies  to  the  use  of  acid  to  venous  haem- 
orrhoids in  old  people.  I  saw  a  very  profuse  haemorrhage 
take  place  in  an  old  man  who  had  been  a  free  drinker,  and 
had  great  dilatation  of  the  veins  at  the  lower  part  of  the 
rectum,  probably  depending  upon  a  diseased  condition  of 
liver.  It  was  not  thought  desirable  to  use  the  ligature,  and 
nitric  acid  was  applied;  it  caused  a  considerable  slough,  and 
bleeding  commeneed  in  four  days;  before,  in  fact,  the 
slough  had  separated.     This  patient  nearly  lost  his  life. 

A  stricture  of  the  rectum  may  result  from  the  use  of  the 
fuming  nitric  acid;  I  have  seen  this  occur  on  several  occa- 
sions, and  very  notably  in  a  girl  at  St.  Mark's  Hospital,  to 
whom  acid  had  to  be  applied  three  times,  and  in  whom  a 
stricture  formed  about  three  and  a  half  inches  from  the  anus; 
this  gave  us  much  trouble,  as,  although  the  bowel  did  not 
come  down,  the  symptoms  were  quite  as  distressing  as  those 
of  that  affection. 

I  have  used  strong  carbolic  acid  in  these  cases;  it  is  not 
likely  to  produce  a  slough,  and  you  may  apply  it  frequently — 
in  fact,  every  day,  if  you  desire  to  do  so;  benefit  results,  but 
the  effect  is  not,  in  my  opinion,  so  permanent  as  that  derived 
from  the  acid  nitrate  of  mercury. 

In  very  bad  procidentia  good  may  be  effected,  but  unfor- 
tunately very  temporary,  by  dissecting  off  triangular  or  ellip- 
tical portions  of  the  mucous  membrane,  and  bringing  the 
edges  together  with  sutures  of  horsehair  or  carbolized  cat- 
gut. Care  must  be  taken,  in  performing  this  operation,  not 
to  remove  more  than  mucous  membrane,  for  if  you  carry 
your  knife  into  the  sub-mucous  tissue,  you  will  get  very  pro- 
fuse haemorrhage.  If  you  like  you  can  clamp  portions  of 
the  gut,  cut  them  away  and  use  the  actual  cautery,  or  you 
may  apply  a  ligature;  I  have  tried  all  these  methods,  but  I 
can  only  say  that  I  have  achieved  very  partial  success;  the 
patient  may  leave  the  hospital  very  well,  and  you  may  con- 
gratulate yourself  upon  having  effected  a  cure,  but  in  a  few 
months  the  bowel  will  again  protrude,  in  all  probability,  as 
badly  as  ever. 


PROCIDENTIA    RECTI.  12 J 

In  the  second  edition  of  this  work  I  said,  "  Dr.  Van 
Buren,  of  New  York,  has  recommended  in  these  intracta- 
ble cases  the  application  of  the  actual  cautery  to  the  gut, 
in  spots  or  lines,  and  also  to  the  verge  of  the  anns  over  ihe 
external  sphincter  muscle,  so  as  to  get  contraction  and  thus 
support  the  bowel.  This  strikes  me  as  a  very  good  sugges- 
tion, and  I  shall  certainly  try  it  on  a  case  where  other  means 
have  failed."  I  have  now  used  this  method  on  many  hos- 
pital and  private  patients  and  effected  permanent  cures. 

The  procidentia  in  the  adult  is  sometimes  very  large;  I 
have  seen  it  in  a  woman,  larger  in  circumference  than  the 
foetal  head,  and  seven  or  eight  inches  in  length. 

I  have  had,  in  my  own  practice,  many  cases  of  prociden- 
tia, in  which  there  was  a  hernial  sac  in  the  protrusion,  and 
in  all  it  was  situated  anteriorly,  as  from  the  anatomy  of  the 
part,  of  course,  it  must  be;  you  could  return  the  intestine 
out  of  the  sac,  and  it  went  back  with  a  gurgling  noise. 

Directly  the  bowel  is  protruded  you  can  tell  that  there  is 
a  hernia  also  present  by  the  fact  that  the  opening  of  the  gut 
is  turned  toward  the  sacrum;  when  the  hernia  is  reduced 
the  orifice  is  immediately  restored  to  its  normal  position  in 
the  axis  of  the  bowel.  I  have  seen  several  similar  cases  in 
the  practice  of  my  colleagues  at  St.  Mark's;  the  condition  is 
therefore  not  very  uncommon,  but  I  have  never  found  it  in 
children. 

In  very  old  and  bad  cases  of  procidentia  more  or  less 
incontinence  of  faeces  always  exists.  There  may  be  two 
reasons  for  this  symptom.  First,  loss  of  tone  in  the  sphinc- 
ters; the  frequent  protrusion  stretching  these  muscles  so  that 
they  lose  a  great  deal  of  their  contractile  power;  and  sec- 
ondly, the  mucous  membrane  gets  so  altered  in  structure  as 
to  lose,  in  a  great  degree,  its  natural  sensitiveness;  thus  when 
fecal  matter  comes  into  the  '  lower  part  of  the  rectum,  the 
sphincters  are  not  stimulated  to  action,  nor  is  the  patient 
aware  of  its  presence. 

The  operation  by  the  hot  iron  or  Paquelin  cautery,  sug- 
gested by  Dr.  Van  Buren,  is  thus  performed  by  me:  The 
patient  is  put  under  the  influence  of  ether,  and  if  the  part 
be  not  down  it  can  be  readily  drawn  fully  out  of  the  anus  by 
the  volsellum.  I  then,  having  the  intestine  held  firmly  out, 
with  the  iron  cautery  at  a  dull  red  heat,  make  four  or  more 
longitudinal  stripes  from  the  base  to  the  apex  of  the  pro- 
truded intestine.  I  take  care  not  to  make  cauterization  so 
deep  toward  the  apex  as  at  the  base,  because  near  the  apex 


128  PROCIDENTIA    RECTI. 

the  peritoneum  may  be  close  beneath  the  intestine,  while  a 
deep  burn  near  the  base  is  not  dangerous.  I  take  care  to 
avoid  the  large  veins  which  can  be  seen  on  the  surface  of 
the  bowel.  If  the  procidentia  be  very  large  I  make  even  six 
stripes.  I  then  oil  and  return  the  intestine  within  the  anus; 
having  done  this  I  partially  divide  the  sphincters  on  both 
sides  of  the  anus  with  a  sawing  motion  of  the  hot  iron,  and 
then  insert  a  small  portion  of  oiled  wool.  From  the  day  of 
operation  I  never  let  the  patient  get  out  of  bed  for  anything; 
the  motions  are  all  passed  lying  down,  consequently  the  part 
never  comes  outside.  If  the  wounds  have  not  all  thor- 
oughly healed  in  a  month,  I  continue  the  recumbent  posi- 
tion for  two  weeks  more,  by  which  time  it  very  rarely  hap- 
pens that  all  is  not  healed.  The  patient  can  then  arise  and 
get  about,  but  still  for  some  time  I  enjoin  that  evacuation  of 
the  motions  should  be  accomplished  lying  down.  The 
reason  for  the  success  of  the  treatment  is  simple  enough. 
When  the  burns  are  all  healed,  the  bowel,  by  contraction  of 
the  longitudinal  stripes,  is  drawn  upward,  and  circumferen- 
tial diminution  also  takes  place.  In  these  cases,  before  ope- 
ration, the  sphincter  muscles  have  quite  lost  power,  the  anus 
is  large  and  patulous;  by  sawing  through  the  anus  with  the 
iron  the  muscles  contract  and  regain  their  power,  the  patient 
having  strength  to  cause  the  anus  to  close  at  will,  and  even, 
to  some  extent,  to  squeeze  the  finger  when  introduced. 
With  this  method  of  treatment  I  have  had  great  success, 
many  persons  being  quite  cured,  while  others  have  been 
greatly  benefited,  so  as  to  be  able  to  work,  by  only  wearing 
a  pad  of  cotton  wadding. 

In  a  case  I  had  with  Dr.  Way,  of  Eaton  Square,  a  lady 
who  had  for  years  suffered  from  a  procidentia  recti  five 
inches  long  and  nearly  three  in  diameter,  a  perfect  cure  was 
effected.  She  wrote  me  on  the  anniversary  of  the  operation, 
to  say  the  bowel  had  never  come  down,  though  she  walked 
very  much  and  had  to  go  up  and  down  flights  of  stairs  con- 
stantly. I  need  not  say  how  grateful  she  was.  In  another 
case  in  the  practice  of  Dr.  Woodhouse,  of  FuUham,  in  which 
several  operations  had  been  performed  unsuccessfully  before 
I  saw  him,  and  the  procidented  intestine  was  very  large,  a 
permanent  cure  was  effected.  In  a  very  bad  case  attended 
by  the  late  Mr.  E.  Carr  Jackson  and  myself,  the  vessels  on 
the  bowel  were  so  large  that  great  bleeding  took  place  when  the 
cautery  was  applied^^  and  ligatures  had  to  be  used.  Secondary 
haemorrhage,  to  an   extent  requiring  very  careful  plugging, 


PROCIDENTIA    RECTI.  I29 

also  occurred  when  the  sloughs  separated.  This  patient 
was  very  anaemic,  through  large  losses  of  blood  prior  to  the 
operations,  and  he  was  blanched  to  a  dirty  white,  yet  he 
thoroughly  recovered,  and  the  bowel  has  never  again  pro- 
truded. This  patient  was  seen  quite  recently  and  remains 
perfectly  well.  Several  hospital  cases  which  I  have  had 
during  the  last  few  years  have  done  admirably,  though  some 
have  required  care  and  watching  for  months  after  the 
operation. 

Sometimes,  when  a  large  portion  of  the  bowel  comes  down, 
there  is  much  difficulty  experienced  in  returning  it.  I  have 
found,  on  several  occasions,  that  the  passing  up  the  bowel  of 
a  large  flexible  bougie,  so  as  to  carry  before  it  the  upper 
part  of  the  descended  gut,  is  of  great  service;  gentle  taxis 
should  at  the  same  time  be  used,  and  in  this  manner  the 
mass  can  generally  be  returned.  When  the  gut  comes  down, 
and  the  patient  cannot  get  it  back  and  does  not  seek  assist- 
ance, it  gets  tightly  girt  about  by  the  sphincter,  great  swell- 
ing takes  place,  and  sloughing  may  ensue.  I  have  seen 
many  cases  of  this  kind,  but,  as  far  as  my  experience  goes, 
the  sloughing  is  partial,  and  only  the  mucous  membrane 
separates.  After  a  few  days'  rest,  with  the  buttocks  well 
raised,  to  favor  the  return  of  blood,  the  part  can  be  replaced 
and  considerable  benefit  may  result.  The  only  case  I  ever 
saw  where  anything  like  dangerous  or  deep  sloughing  took 
place  was  in  consultation  with  a  medical  man  who  had  most 
assiduously  and  constantly  applied  a  bladder  of  ice  to  the 
protruded  part,  and  this  had  so  much  favored  sphacelus 
that  nearly  the  whole  mass  came  away,  and  there  was  free 
secondary  haemorrhage.  In  this  case  the  sloughing  was  so 
considerable  that  a  very  intractable  stricture  resulted.  This 
shows  the  necessity  of  care  in  the  application  of  ice;  if  it  be 
too  long  continued,  or  if  the  patient  be  old  or  of  feeble  con- 
stitution, dangerous  results  may  ensue. 

I  am  not  aware  of  any  internal  remedy  which  is  of  much 
use  in  cases  of  procidentia,  but  small  and  frequent  doses  of 
opium,  with  confection  of  black  pepper,  benefited  some  of 
my  patients. 

A  nasty,  teasing  diarrhoea  is  very  commonly  present,  and 
there  is  often  a  discharge  of  mucus,  which  keeps  the  linen 
always  damp,  and  adds  not  a  little  to  the  general  discomfort. 
Powdered  acorns  I  have  used  frequently  with  advantage,  for 
the  diarrhoea.  The  acorns  should  be  baked  and  grated  to 
powder,  and  the  dose  is  one  teaspoonful  in  half  a  tumbler  of 


130  POLYPUS    RECTI. 

milk  every  morning.     I  have  found  this  answer  better  than 
either  gallic  or  tannic  acid. 

The  frequent  and  bountiful  application  of  cold  water  in 
these  cases  is  to  be  strongly  recommended.  It  is  as  useful 
as  ordinary  astringent  lotions. 


CHAPTER  XIII. 

POLYPUS   RECTL 

This  disease  was  formerly  looked  upon  as  a  very  rare  one; 
recently,  however,  it  has  been  considered  rather  more 
common,  and  it  is  supposed  that  in  times  gone  by,  rectal 
maladies  not  being  so  well  understood,  many  cases  of  poly- 
pus escaped  diagnosis.  At  a  meeting  of  the  Pathological 
Society,  in  February,  1873,  a  gentleman  stated  that  he  had 
seen  fifteen  cases  in  twelve  months.  His,  I  think,  must  be 
a  somewhat  singular  experience.  I  find  that  I  have  noted 
altogether  6;^  cases  without  complication,  as  having  occurred 
in  my  own  practice.  My  statistics  at  St.  Mark's  Hospital 
shows  that  in  4000  cases  of  rectal  disease  there  were  only 
sixteen  of  polypus  without  fissure. 

It  has  generally  been  believed  that  polypi  are  much  more 
frequently  found  in  children  than  in  adults;  this  has  not 
been  the  case  in  my  experience,  as  ;^6  existed  in  children 
under  fourteen  years  of  age,  and  27  in  older  persons. 

By  the  word  "  polypus  "  I  must  be  understood  to  mean  a 
pedunculated  growth  attached  to  the  mucous  membrane  of 
the  rectum,  and  generally  situated  not  less  than  an  inch 
from  the  anus.  I  have  seen  them  quite  two  inches  up  the 
bowel,  but  only  occasionally  more  than  that  distance.  In 
the  majority  of  cases  the  polypus  grows  from  the  dorsal 
portion  of  the  rectum,  but  I  have  found  it  on  the  perineal 
and  lateral  segments.  I  think  some  surgeons  apply  the 
term  "  polypus "  to  those  small  muco-cutaneous  polypoid 
growths  which  are  so  often  found  at  the  upper  end  of  a 
fissure,  and' thus  swell  their  statistics. 

My  friend  Dr.  Daniel  Molliere,  of  Lyons  (whose  work  on 
rectal  surgery  surpasses  all  others  in  its  pathology),  says, 
*'  There  is  no  word  in  surgery  that  has  been  more  abused  in 


POLYPUS   RECTI.  I3I 

its  use  than  the  word  polypus,  especially  when  applied  to 
tumors  of  the  rectum.  As  a  matter  of  fact,  the  term  '  poly- 
pus of  the  rectum '  is  used  to  describe  any  neoplasm,  no 
matter  whether  benign  or  malignant,  hard  or  soft,  provided 
only  that  it  adheres  to  the  rectum  by  a  stalk  or  relatively 
limited  base." 

Polypi  have  been  usually  described  as  of  two  kinds;  the 
soft  or  follicular,  and  the  hard  or  fibrous — the  former  being 
found  in  children,  and  the  latter  in  grown-up  persons.  I  do 
not  concur  in  the  statement  that  the  soft  polypus  is  always 
the  one  found  in  young  children,  and  I  am  of  opinion  that 
the  true  fibrous  variety  is  rare  even  in  the  adult.  In  fact, 
this  rough  division  is  very  far  from  the  pathological  truth, 
for  the  true  fibrous  polypus,  in  its  anatomy,  is  an  almost 
perfect  counterpart  of  the  fibroid  tumor  of  the  uterus.  In 
the  Hunterian  Museum  is  one  specimen  of  rectal  polypus 
arising  from  the  muscular  fibres  of  the  rectum,  and  it  is  in 
reality  a  fibro-muscular  tumor,  or,  in  the  nomenclature  of 
Virchow,  a  myoma.  The  few  I  have  s^n  myself  have  been 
nearly  as  large  as  an  English  walnut;  they  creak  when  cut, 
and  the  incised  surface  is  of  a  pale  color.  The  peduncle  is 
about  an  inch  and  a  half  long,  and  is  always  attached  above 
the  sphincters;  the  tumors  do  not  usually  appear  outside  the 
anus,  they  do  not  bleed,  but  when  they  do  protrude  they 
cause  pain,  irritation,  and  spasm,  and  often  set  up  an  ulcer 
in  the  bowel.  The  discharge  from  them  is  of  a  very  icho- 
rious  and  ill-smelling  character.  These  polypi  have  been 
observed  and  minutely  described  by  both  French  and  Ger- 
man pathologists,  and.  are  considered  quite  exceptional' 
specimens  of  this  form  of  tumor. 

The  polypi  usually  found  in  the  adult  are  smaller  than  the 
mucous  polypi  of  children;  they  are  multiple.  I  have  often 
found  two  growing  from  opposite  sides  of  the  rectum;  there 
may  also  be  two  stems  with  one  head  only.  The  pedicle 
may  be  an  inch  or  a  little  more  in  length,  and  is  not  uncom- 
monly hollow;  the  polypi  are  neither  very  hard  nor  soft,  and 
are  easily  compressible;  they  are  sometimes  cystic;  a  large 
vessel  runs  up  the  stem;  in  some  cases  you  can  feel  it  pul- 
sate. 

The  soft  follicular  polypus  of  children  is  no  doubt  rarely 
met  with  in  adults,  but  even  in  these  it  is  not  so  rare  as  my 
colleague,  Mr.  Gowlland,  believes,  who  once  stated  at  the 
Medical  Society  that  there  were  only  two  kinds  of  polypi, 
"the  soft  and  the  hard."     He  had  evidently  not  consulted 


132  POLYPUS   RECTI. 

the  writings  of  foreign  pathologists,  or  he  would  have  found 
that  there  are  numbers  of  different  forms.  The  soft  polypus 
is  almost  always  found  in  women,  and  thus  Dr.  Routh  is  likely, 
as  he  says,  to  have  seen  a  considerable  number.  The  stem  is 
remarkably  long  and  rather  slender. 

The  polypi  of  children  are  small,  vascular  tumors,  with  a 
peduncle  often  two  inches  long.  They  are  about  the  size  of 
a  raspberry,  and  resemble  a  small,  half-ripe  mulberry  more 
than  anything  else;  they  bleed  very  freely  at  times,  and 
occasion  in  the  young  great  debility.  They  are  said  to  be 
either  hypertrophies  of  the  glands  of  Lieberkiihn,  or  of  the 
mucous  follicles  of  the  rectum.  They  may  be  dangerous 
when  high  up,  by  occasioning  intussusception  of  the  bowel, 
with  total  obstruction  and  death.  When  the  peduncle  is 
more  than  an  inch  in  length  they  usually  protrude  at  stool, 
and  require  to  be  returned  after  the  bowels  are  relieved. 
They  are  sure  to  be  described  by  the  child's  mother  as  piles, 
or  as  "  the  body  coming  down." 

The  peduncle  is  ^something  so  slender  that  it  breaks  on 
very  slight  traction,  and  I  dare  say  many  polypi  become 
detached  when  the  child  is  straining  or  passing  a  hard 
motion,  and  are  thus  spontaneously  cured. 

A  most  valuable  and  original  account  of  polypi  in  children, 
by  the  late  Dr.  Bathurst  Woodman,  and  founded  on  his 
experience  at  the  Northeastern  Hospital  for  Children,  may 
be  found  in  the  Medical  Press  and  Circular^  May  5th,  1875. 
He  names  five  kinds  of  polypi — i,  the  soft  and  gelatinous; 
2,  the  cystic;  3,  the  papillomatous;  4,  the  dermoid;  5,  the 
sarcomatous.  Dr.  Woodman  states,  that  the  most  common 
variety  in  children  is  the  hard  polypus  (I  must  say  that  such 
has  not  been  my  experience),  and  that  "  the  children  of 
arthritic  parents,  and  those  suffering  from  the  syphilitic, 
tuberculous,  and  cancerous  cachexiae  are  most  liable  to  these 
affections." 

From  the  polypus  of  the  adult  I  have  often  seen  abscess, 
ulcer  or  fissure,  and  fistula  arise.  A  short  time  since  a 
patient  was  sent  to  me  with  a  fistula,  complete  and  dorsal; 
the  probe  passed  readily  through  it  into  the  bowel.  On 
introducing  my  finger  I  found  the  internal  opening  very 
large,  a  hard  polypus  as  big  as  a  marble  projected  into  it; 
the  stem  was  quite  half  an  inch  long,  and  was  attached  near 
the  promontory  of  the  sacrum.  I  have  seen,  on  post-mortem 
examination  in  both  adults  and  children,  full-sized  polypi 
attached  as  high  as  the  sigmoid  flexure  of  the  colon,  and 


POLYPUS   RECTI.  I33 

also  in  the  colon  itself ;  they  cause  diarrhoea  and  may  bring 
on  obstruction  of  the  bowel  by  setting  up  inflammation, 
which  occasions  paralysis  of  the  muscular  coat  of  the  intes- 
tine. When  fissure  exists  with  polypus,  the  removal  of  the 
polypus  and  gentle  dilatation  will  cure  both  maladies. 

The  diagnosis  of  polypus  has  been  stated  to  be  difficult.  I 
cannot  myself  see  why  any  difficulty  should  arise.  The  his- 
tory of  the  case  and  symptoms  will  usually  lead  you  to  sus- 
pect what  the  disease  is,  and  if  you  are  careful  to  administer 
an  injection  and  thoroughly  search  the  bowel  you  must  feel 
or  see  it.  When  a  polypus  has  a  long  pedicle  it  is  apt  to 
slip  away  from  the  finger,  but  even  then  the  peduncle  can  be 
readily  felt  at  its  point  of  attachment  to  the  rectum. 

The  general  symptoms  in  children  are — frequent  desire  to 
go  to  stool,  accompanied  by  tenesmus,  occasional  bleeding, 
with  discharge  of  mucus,  and  a  fleshy  mass  protruding  from 
or  appearing  at  the  anus  when  the  bowels  are  acting. 

It  is  possible  to  mistake  this  disease  for  internal  piles,  pro- 
cidentia recti,  or  dysentery.  An  examination  after  an  injec- 
tion will  clear  up  the  doubt  in  the  first  two  cases;  in  the  last, 
the  presence  of  fever,  the  abdominal  pain,  and  the  appear- 
ance of  the  motions  are  sufficiently  distinctive  indications. 

In  the  adult  the  history,  carefully  inquired  into,  may  be 
found  peculiar.  The  patient  will  tell  you  that  without  any 
previous  marked  discomfort  in  the  rectum,  he  all  at  once 
discovered  that  a  substance  protruded  on  going  to  the  closet. 
1  his  is  characteristic  of  the  malady;  until  the  peduncle 
becomes  long  enough  to  allow  of  the  polypus  being  extruded 
or  grasped  by  the  external  sphincter,  but  little  or  no  incon- 
venience is  felt,  therefore  the  onset  of  the  disease  is  consid- 
ered by  the  patient  as  sudden;  this  is  quite  different  from 
the  history  of  haemorrhoids. 

I  cannot  at  all  say  why  these  growths  should  arise;  they 
are  not  often  connected  with  haemorrhoids  or  any  other  dis- 
eases of  the  rectum  save  fissure  and  intussception.  I  have 
not  even  observed  that  constipation,  that  potent  factor  of 
bowel  affections,  obtains  in  these  cases.  I  will  relate  a  few 
cases  of  polypus,  and  then  say  a  word  or  two  about  treat- 
ment. 

Thos.  B. — ,  set.  4,  seen  at  the  Farringdon  Dispensary, 
October  27th,  1862.  For  more  than  twelve  months  has  had 
what  was  supposed  to  be  prolapsus  of  the  bowel;  he  lost  a 
good  deal  of  blood  at  times,  and  was  very  feeble  and 
anaemic.     After  an  injection  there  came  down  to  the  anus 


134  POLYPUS    RECTI. 

a  spongy,  irregular-shaped,  bleeding  mass,  fully  as  large  as  a 
medium-sized  walnut ;  it  felt  soft,  but  not  gelatinous.  A 
tolerably  long  pedicle  connected  it  with  the  anterior  wall  of 
the  rectum.  I  applied  a  ligature  and  cut  the  polypus  off. 
He  was  ordered  an  astringent  draught  to  confine  the  bowels 
for  a  few  days.  November  ist.  He  took  a  dose  of  castor 
oil  and  the  ligature  came  away  on  the  bowels  acting.  There 
was  no  bleeding.     Discharged  cured. 

Jane  H — ,  aet.  7,  brought  to  St.  Mark's  Hospital,  October, 
1864.  Her  mother  said  that  something  came  down  when  the 
bowels  acted,  and  she  lost  much  blood;  she  was  obliged  to 
put  the  substance  back  again.  After  an  injection  two  tumors 
made  their  appearance,  and  I  at  first  thought  it  was  a  case  of 
haemorrhoids;  but  on  closer  examination,  passing  my  finger 
into  the  rectum,  I  found  that  they  were  polypi,  arising  by  two 
peduncles  from  quite  an  inch  and  a  half  up  the  bowel.  One 
appeared  to  be  attached  dorsally,  and  the  other  laterally.  I 
applied  two  ligatures  and  snipped  off  the  growths.  In  three 
days  the  ligatures  came  away,  and  she  was  soon  quite  well. 

Henry  de  C — ,  admitted  into  St.  Mark's,  March,  1866.  He 
was  six  years  old,  and  looked  a  very  feeble,  delicate  boy. 
For  two  or  three  years  he  had  lost  blood  at  stool,  and  latterly 
something  had  protruded  after  an  evacuation;  it  had  to  be 
returned  by  pressure.  He  had  taken  a  quantity  of  medicine, 
and  been  treated  at  several  public  institutions.  After  an 
injection  a  dark-colored,  very  vascular  polypus  came  into 
view;  it  had  a  well-defined,  rather  thick  neck.  I  applied  a 
ligature  and  cut  through  the  pedicle;  the  tumor  was  about 
the  size  of  a  raspberry.  The  thread  separated  in  five  days, 
and  there  was  no  haemorrhage.  I  kept  him  under  observation 
some  time,  giving  him  tonics;  he  was  ultimately  discharged, 
perfectly  recovered. 

Hugh  L — ,  aet.  9,  a  weak  and  irritable  boy,  emaciated  and 
bloodless,  suffers  from  cough.  His  mother  says  he  has  been 
troubled  for  five  years,  at  least,  with  his  bowel  coming  down 
whenever  he  went  to  the  closet.  He  returned  it  himself  by 
pressure.  He  had  been  taken  to  medical  men,  and  also  to 
hospitals,  and  she  had  been  told  that  it  was  a  weakness  of 
the  bowel,  and  had  used  ointments  and  lotions  for  it.  The 
loss  of  blood  he  had  sustained  lately  had  been  very  severe. 
He  did  not  suffer  any  pain.  When  I  first  saw  him  his 
mother  said  ''  his  body  "  would  come  down  if  he  stooped  and 
strained  a  little,  and  on  his  doing  so  a  round,  vascular,  bright- 
red,  villous  body,  bleeding  freely,  was  seen  outside  the  anus. 


POLYPUS   RECTI.  I35 

It  was  not  at  all  painful  to  the  touch.  I  found  that  it  was 
connected  with  the  bowel  just  above  the  internal  sphincter, 
by  a  pedicle  of  pale  color,  at  least  two  inches  long.  I  applied 
a  silk  ligature  and  ordered  him  a  little  aromatic  confection, 
to  confine  the  bowels.  In  three  days  the  ligature  separated 
on  action  taking  place.  I  then  prescribed  for  him  some  iron 
and  cod-liver  oil.  In  a  fortnight  they  brought  him  again, 
saying  that  another  substance  had  made  its  appearance,  and 
sure  enough,  on  his  straining,  a  tumor,  almost  precisely  sim- 
ilar to  the  former  one,  protruded  from  the  anus.  To  this 
also  I  applied  a  ligature.  When  I  saw  him  at  the  end  of  the 
week  I  administered  an  injection  to  see  if  there  were  any 
more  polypi,  but  I  found  none,  so  I  discharged  him  as  cured. 

Duncan  J — ,  set.  i8,  came  to  St.  Mark's  in  1867.  His 
health  was  generally  good.  For  twelve  months  he  had  some- 
thing protrude  from  the  anus  on  visiting  the  water  closet, 
and  he  had  lost  a  quantity  of  blood.  It  retracted  spontane- 
ously on  his  rising  up  after  the  action.  He  has  been  under 
the  care  of  many  physcians  and  surgeons,  and  has  always 
been  treated  for  bleeding  piles.  He  has  a  pain  of  a  dragging, 
burning  character  in  the  rectum,  but  it  is  not  severe.  After 
an  injection  a  large  (the  size  of  a  walnut),  vascular,  velvety- 
looking  polypus  appeared  at  the  verge  of  the  anus.  The 
pedicle  was  rather  thin,  and  not  so  long  as  usual.  I  held  it 
with  a  volsellum  while  the  house-surgeon  applied  a  ligature; 
this  was  pulled  so  tight  that  it  cut  the  peduncle  at  once.  I 
was  apprehensive  of  bleeding,  and  so  kept  him  lying  down  in 
the  out-patients'  room  for  a  couple  of  hours,  when,  finding 
there  was  no  haemorrhage,  I  sent  him  home.  In  a  week  he 
came  and  said  he  was  quite  well. 

Martha  H — ,  aet.  25;  married;  no  children;  several  mis- 
carriages; admitted  into  St.  Mark's,  1865.  She  had  one 
perineal  hsemorrhoid  and  a  dorsal  fibrous  polypus,  the  size  of 
hazel-nut.  The  polypus  had  a  shortish  broad  pedicle;  it 
was  situated  above  the  internal  sphincter,  and  I  found  some 
difficulty  in  applying  the  ligature.    She  left  the  hospital  well. 

Mr.  James  B — ,  set.  37,  was  sent  to  me  by  a  medical  man 
who  thought  he  was  suffering  from  piles  After  an  injection 
a  polypus  came  down,  resembling  much  that  found  in 
children,  but  it  was  firm  and  not  so  vascular;  it  was  about 
the  size  of  a  raspberry.  I  placed  a  ligature  on  the  stem  and 
cut  it  off.  This  gentleman  did  not  rest,  as  I  advised  him  to 
do,  for  a  few  days,  and  he  had  an  abscess  form  a  week  after 
the  separation  of  the  ligature. 


136  PRURITUS   ANl. 

A  lady,  set.  46,  who  had  been  supposed  to  be  suffering 
from  some  uterine  affection,  was  sent  to  me  by  Dr.  Priestley. 
He  had  found  on  examination  that  the  patient's  symptoms 
were  due  to  a  polypus  of  the  rectum;  this  was  easily  felt 
from  the  vaginia.  I  removed  the  polypus,  and  the  patient 
soon  recovered. 

•  These  cases  of  polypus  forcibly  illustrate  the  desirability 
of  always  giving  an  enema  before  making  an  examination,  as 
it  is  only  by  seeing  the  patient  just  after  the  bowels  have 
acted  that  you  can  make  certain  of  your  diagnosis. 

The  only  treatment  to  be  recommended  is  the  removal  of 
the  growth.  I  do  not  think  it  safe  either  to  cut  or  tear 
polypi  off,  as  troublesome  arterial  haemorrhage  may  ensue. 
I  have  seen  them  bleed  very  freely  indeed,  and,  as  they  are 
attached  at  some  distance  from  the  anus,  it  would  be  by  no 
means  easy  to  place  a  ligature  upon  the  bleeding  vessel. 

I  have  used  the  clamp  and  actual  cautery  twice,  and  it 
answered  very  well,  but  it  is  rather  a  formidable  proceeding, 
the  idea  of  hot  irons  frightening  the  patient,  although  really 
the  operation  is  painless,  as  also  is  the  ligature;  the  latter 
has  the  advantage  of  being  always  at  hand.  The  simplest 
method,  however,  is  to  seize  the  peduncle  close  to  its  base, 
with  the  German  catch  torsion  forceps,  and  gently  twist  the 
polypus  around  until  it  comes  away.  There  is  no  danger  of 
haemorrhage,  no  pain,  and  scarcely  any  necessity  for  resting 
more  than  one  day. 

If  a  ligature  be  used,  I  think  it  is  very  desirable  that  the 
patient  should  rest  until  it  separates,  and  I  usually  order  a 
mild  astringent  draught,  to  keep  the  bowels  confined,  for 
three  days,  then  I  administer^an  aperient,  and  on  relief  tak- 
ing place  the  ligature  comes  away.  In  two  cases  I  have  seen 
abscesses  follow  where  much  exercise  had  been  taken. 


CHAPTER  XIV. 

PRURITUS    ANI. 


Pruritus  ani,  or,  as  it  may  well  be  called,  painful  itching 
of  the  anus,  is  a  most  distressing  malady.  I  have  often 
heard  a  patient  say  that  his  or  her  life  was  rendered  almost 


PRURITUS   ANI.  137 

unendurable  by  it.  In  fact,  one  very  nervous  invalid  told 
me  that  unless  he  had  obtained  relief,  he  believed  that  he 
should  have  gone  out  of  his  mind.  It  is  very  intractable, 
but  I  am  confident  that  it  is  always  curable  if  the  patient 
will  strictly,  patiently,  and  persistently  follow  the  advice  of 
his  medical  attendant. 

The  disorder  is  frequently  induced,  or  at  all  events  kept 
up,  by  habits  of  too  free  eating  and  drinking,  and  its  success- 
ful treatment,  therefore,  calls  for  a  considerable  amount  of 
self-denial  on  the  part  of  the  patient ;  and  thus  it  often  hap- 
pens that  as  soon  as  the  sufferer  gets  relieved  he  forgets  all 
his  prudent  resolutions  and  relapses  into  his  old  way  of  life 
— a  step  which  is  pretty  certain  to  result  in  the  return  of  his 
enemy  in  full  force.  He  then  usually  blames  his  doctor, 
very  rarely  himself,  and  either  gives  up  in  despair  all  hope 
of  cure,  or  seeks  new  advice,  so  that  the  affection  comes  to 
be  considered  as  not  only  an  exceedingly  troublesome  one, 
but  almost  incurable.  I  can  truly  state  that  I  have  rarely, 
if  ever,  failed  to  cure  a  patient  who  adhered  rigidly  to  my 
directions  ;  and  when  a  person,  the  subject  of  bad  pruritus, 
comes  to  me,  I  always  say,  "  Unless  you  intend  to  conform 
most  religiously  to  my  directions,  as  long  as  I  think  necess- 
ary, I  cannot  cure  you,  and  I  had  much  rather  that  you  con- 
sulted some  other  surgeon."  Although,  as  I  have  said,  free 
living  often  induces  pruritus,  I  have  met  with  many  cases  in 
very  abstemious  persons  ;  I  have  seen  a  most  ascetic  clergy- 
man suffer  dreadfully,  and  I  have  had  under  my  care  a  lady 
who  nearly  all  her  life  has  been  a  total  abstainer  from  alco- 
hol, and  is  a  remarkably  small  eater,  yet  she  has  been 
quite  a  martyr  to  this  complaint. 

The  irritation,  in  the  majority  of  cases,  is  worse  at  night, 
especially  when  the  patient  gets  warm  in  bed,  so  that  often 
the  greater  part  of  the  night  is  rendered  sleepless  and  inex- 
pressibly wretched;  towards  the  morning,  irritable  and  worn 
out,  he  falls  off  into  a  fitful  slumber,  from  which  he  often 
awakens  himself  by  scratching ;  this,  of  course,  makes  the 
part  more  or  less  raw,  and  materially  adds  to  his  discomfort 
in  the  daytime.  I  need  scarcely  say  that  the  more  the  suf- 
ferer scratches  the  worse  he  makes  himself,  although  it  is 
very  difficult  indeed  to  avoid  seeking  the  temporary  relief  it 
affords.  Many  persons  have  told  me  they  would  infinitely 
prefer  decided  pain  to  the  dreadful  and  constant  itching 
they  have  to  endure,  which  really,  after  a  time,  becomes  pain 
of  a  most  sickening  character.     Excitable  people  are  often 


138  PRURITUS    ANT. 

greatly  troubled  in  the  day  as  well  as  at  night,  the  itching 
setting  in  badly  after  exercise  or  on  leaving  the  cold  air  and 
coming  into  a  warm  room. 

Doubtless  there  are  many  cases  of  pruritus  for  which  we 
are  unable  to  assign  any  cause,  and  it  may  then  be  consid- 
ered as  a  pure  neurosis  ;  but  usually  it  is  possible  to  dis- 
cover some  reason  for  the  irritation  in  derangement  of  other 
organs.  The  secauses  may  be  mentioned — liver  affections, 
internal  haemorrhoids,  constipation,  anything  causing  press- 
ure upon  the  hsemorrhoidal  veins  so  as  to  retard  the  return 
of  blood  from  the  rectum,  disorders  of  the  stomach  induced 
by  errors  in  diet,  latent  gout,  uterine  diseases,  and  we  must 
not  forget  parasites,  as  vegetable  growths,  pediculi  similar  to 
those  found  on  the  pubes,  and  ascarides. 

It  is  generally  stated  that  there  is  a  very  little  alteration 
in  the  aspect  of  the  part  affected,  and  that  nothing  is  to  be 
observed  beyond  a  roughened,  thickened  and  more  rugose 
state  of  the  skin  just  around  the  anus.  This  I  think  is  by 
no  means  usually  the  case;  sometimes  there  is  a  distinctly 
eczematous  rash,  the  part  being  always  moist  from  exuda- 
tion; at  others  there  is  a  dry,  rugose  condition,  with  bright 
redness  consequent  upon  scratching;  occasionally  there  are 
a  quantity  of  minute  scales  to  be  seen,  forming  irregular 
rings;  often  cracks  are  seen  radiating  from  the  anus,  and 
even  extending  up  to  the  sacrum;  but  what  I  consider  the 
characteristic  condition — which  may  ahyays  be  noticed 
when  the  disease  is  severe,  and  has  lasted  for  any  length  of 
time — is  the  loss  of  the  natural  pigment  of  the  part.  To 
such  an  extent  does  this  often  obtain,  that  patches  around 
the  anus,  extending  backward  as  far  as  the  sacrum  and  for- 
ward to  the  scrotum,  are  of  a  dull,  dead  white,  the  skin 
looking  more  like  very  white  parchment  than  natural  integu- 
ment, and  if  you  pinch  it  up  you  will  feel  that  it  has  lost  its 
normal  elasticity.  I  have  seen  a  similar  condition  induced 
by  genital  pruritus  in  women. 

When  considering  a  case  as  to  the  question  of  treatment, 
it  is  always  important  to  discover  the  cause  of  the  irritation; 
particular  articles  of  diet  or  drink  affect  some  persons  in  a 
remarkable  manner.  I  once,  had  a  patient  who  invariably 
got  an  attack  of  pruritus  from  eating  lobster  or  crab,  and  of 
these  shellfish  he  was  inordinately  fond,  but  rarely  dared  to 
indulge  his  taste.  I  have  seen  a  similar  result  from  eating 
salmon.  Another  of  my  patients  was  sure  to  suffer  if  he 
drank  any  quantity  of  champagne  or  ale,  and  the  irritation. 


PRURITUS    ANI.  139 

once  started  was  very  difficult  to  arrest.  There  is  but  little 
doubt  that  excess  at  table,  combined  with  a  want  of  active 
exercise,are  not  only  a  predisposing  but  also  an  exciting  cause. 
Excessive  smoking  is  another  excitant  of  the  disorder;  I 
have  seen  several  instances  (where  patients  had  a  tendency 
to  the  malady)  of  over-indulgence  in  smoking  being  fol- 
lowed immediately  by  an  attack  of  pruritus. 

Spare  no  pains  to  investigate  closely  the  habits  of  your 
patient.  Stout,  plethoric  people  should  be  put  on  a  rather 
low  diet;  they  should  avoid  all  rich  and  highly  seasoned 
dishes,  eat  but  little  meat,  and  take  fish,  poultry,  vegetables, 
and  ripe  fruits.  Interdict  both  beer  and  spirits,  and  restrict 
the  drinking  to  a  little  light  sherry  or  claret  and  Vichy  or 
Seltzer  water.  Coffee  should  be  given  up,  weak  tea  or 
cocoa  being  taken  at  breakfast.  Enjoin  a  walk  of  three  or 
four  miles  daily,  and,  if  possible,  at  such  a  speed  as  to 
induce  slight  perspiration;  let  the  patient  take  a  sponge  bath 
every  morning,  a  warm  or  Turkish  bath  once  in  the  week, 
and  every  night  when  retiring  to  bed  wash  the  anus  and 
parts  around  with  warm  water  and  tar  or  Castile  soap.  If 
the  bowels  are  at  all  confined  the  following  prescription  will 
be  found  beneficial: 

^.    Magnes  Sulph 3j 

Magnes.  Carb.  pond gr.  v 

Vini  Colchici mv 

Syrupi  Sennae 3  j 

Tinct.  Cardam.  comp 3  ss 

Ex.  Inf.  Chiratae §  j  M. 

Twice  or  thrice  in  the  day. 

And  I  also  often  order — 

]^ .    Pil.  Plummer gr.  ij 

Til.  Rhei.  comp gr.  iij  M. 

To  be  taken  every  other  night  for  a  week. 

The  mineral  waters  of  Carlsbad,  Friedrichshall,  Vichy, 
Hunyadi  Janos,  Pullna,  etc.,  are  good  remedies,  and  I  fre- 
quently employ  them. 

After  the  washing  at  night  let  the  patient  apply  this  oint- 
ment freely: 

3 .    Hydrarg.  Subchlor gr.  x 

Ung.  Sambuci 3  j  M. 


I40  PRURITUS   ANI. 

Or  this  lotion,  which,  is  very  efficacious  in  allaying  irrita- 
tion : — 

^ .    Sodse  Biboratis 3  ij 

Morphias  Hydrochlor gr.  xvj 

Acidi  Hydrocyanic,  dil |  ss 

Glycerinse |  ij 

Aquae ad   §  viij.         M. 

Dab  the  part  frequently.  A  chloroform  pomade  made 
thus  is  often  useful: — 

^ .    Chloroform 3  ij 

Glycerinae |  ss 

Ung.  Sambuci |  iss.         M. 

A  lotion  of  borax  with  colchicum,  a  saturated  solution  of 
borax,  the  Ung.  Boracis  c.  Vaseline  (gr.  x,  ad  3  j),  the  sul- 
phide of  calcium  internally  and  externally,  as  recommended 
by  Hebra,  a  pap  of  Tenax,  are  other  remedies  that  may  be 
tried.  Sir  Benjamin  Brodie  had  much  success  from  the 
white  precipitate  ointment.  The  following  prescription  of 
the  late  Mr.  Startin  has  been  of  great  service  to  many 
patients  suffering  from  eczema.  I  have  seen  a  bad  case 
cured  in  forty-eight  hours  by  its  application  alone: — 

5"    Liquoris  Carbonis  Detergent. 

(Wright's)  Glycerinae aa. . . .  |  j 

Zinci  Oxidi,  Pulv. 

Calamin.  prep aa . . . .  |  ss 

Pulv.  Sulph.  precip 3  ss 

Aquae  purae ad |  vj.         M. 

The  part  affected  to  be  painted  thickly  over  once  or  twice 
daily  and  allowed  to  dry.  Lastly,  I  must  not  omit  to  men- 
tion carbolic  acid,  with  glycerine  or  water,  as  being  very 
useful,  and  also  prophylactic,  after  other  treatment  has  suc- 
ceeded. 

All  remedies  may  for  a  time  be  disappointing,  and  in 
long-standing  cases  you  must  be  prepared  to  alter  your  pre- 
scriptions until  you  find  what  best  suits  your  patient.  In 
old  and  feeble  persons  the  combination  of  the  sulphates  of 
iron  and  magnesia  with  dilute  sulphuric  acid  and  infusion 
of  quassia  often  does  good;  with  it  I  have  cured  a  number 
of  elderly  people  whose  lives  were  embittered  by  long  con- 
tinued itching.     Often  in  them  the  parts  are  quite  raw,  and 


PRURITUS    ANI.  141 

discharge  an  ichorous  irritating  fluid,  The  tonic  and  laxa- 
tive mixture  above  mentioned,  and  the  borax  lotion,  with 
great  attention  to  washing  the  part  with  warm  water  and 
Castile  soap,  have  usually  been  followed  with  great  benefit 
and  ultimate  cure. 

When  you  have  made  up  your  mlhd  that  the  essence  of 
the  disease  is  in  the  nervous  system,  as  I  think  it  often  is, 
particularly  in  spare  and  delicate,  excitable  people,  you 
should  give  arsenic  and  quinine  freely,  and  be  prepared  to 
push  them  to  their  physiological  effect.  They  may  be  taken 
separately  or  combined.  I  have  rarely  failed  to  cure  this 
class  of  cases  by  pereverence  in  these  remedies;  at  the  same 
time,  of  course,  using  local  means  to  allay  irritation.  In 
obstinate,  old-standing  cases  I  usually  commence  the  treat- 
ment by  rubbing  the  parts  thoroughly  with  a  solution  of 
nitrate  of  silver,  3ij  to  the  ounce;  this  softens  the  skin  and 
induces  a  more  healthy  action  and  secretion.  At  times  I 
have  found  Condy's  fluid,  undiluted,  useful  for  the  same 
purpose;  it  should  be  applied  twice  or  oftener  in  the  week. 

The  disorder  is  not,  by  any  means,  so  common  in  women 
as  in  men,  nor  is  it  frequently  met  with  in  young  persons  ; 
but  one  of  the  most  obstinate  cases  I  ever  had  occurred  in 
a  delicate  lad  of  seventeen.  There  did  not  appear  to  be  any 
ascertainable  cause  for  the  irritation,  and  he  was  eventually 
cured  by  Liquor  Potassae  Arsenitis  in  full  doses  and  cod- 
liver  oil.  I  had  once  a  very  intractable  case  in  a  man  nearly 
eighty  years  of  age,  who  was  an  inmate  of  the  Bookbinders' 
Almshouses  at  Kingsland;  it  resisted  all  remedies  for  some 
time,  but  eventually  yielded  to  arsenic  internally  and  the 
strong  caustic  solution  frequently  applied.  In  women  the 
uterine  functions  should  be  attended  to;  and  I  have  fre- 
quently found  the  citrate  of  iron,  quinine,  and  strychnine 
very  advantageous. 

I  have  met  with  a  good  many  examples  of  latent  gout  as  a 
cause  of  pruritus  ani. 

A  gentleman  was  under  my  care  some  time  ago  who  had 
often  suffered  from  pruritus,  and  always  got  rid  of  it  when 
gout  attacked  him,  and  he  was  free  for  some  time  afterwards. 
Here  diet  is  a  most  important  element  in  the  treatment.  I 
think  the  irritation  is  best  allayed  by  a  strong  solution  of 
bicarbonate  or  bisulphate  of  soda  frequently  applied  in  a 
poultice.  I  have  formed  a  good  opinion  of  the  usefulness 
of  lithia  water  and  the  effervescing  citrate  of  lithia.  In  some 
cases,  where  the  irritation  is  very  severe,  colchicum   with 


142  PRURITUS    ANI. 

alkalies  answers  best,  but  if  it  can  be  managed,  a  course  of 
waters  at  Baden-Baden,  Ems,  or  Carlsbad,  will  be  found 
most  beneficial. 

I  have  a  very  excitable,  nervous  patient  who  frequently 
gets  an  attack  of  pruritus  when  he  is  mentally  overworked 
or  irritated,  and  in  this  and  similar  cases  I  have  found  the 
bromide  of  potassium  very  advantageous,  and  I  have  com- 
bined with  this  ten  or  fifteen  grains  of  the  hydrate  of  chloral, 
This  mixture  taken  at  bedtime  generally  ensures  a  fair  night. 
An  extended  experience  in  this  class  of  cases  has  induced 
me  to  think  most  highly  of  the  bromide  of  potassium  and 
chloral  in  combination.  In  alternation  with  the  chloral  I 
have  seen  great  advantage  result  from  the  Succus  Conii  in 
full  doses  (one  to  two  drachms  given  three  times  in  the  day); 
to  this  may  be  added  cod-liver  oil  after  meals,  by  which 
means  I  think  you  may  repair  nerve-tissue  and  induce  a 
more  regular  distribution  of  nerve-force.  I  am  fully  con- 
vinced that  the  more  you  treat  pruritus  ani  as  a  general  dis- 
ease the  more  successful  you  will  be;  the  difficulty  in  curing 
it  has  arisen  in  great  measure  from  its  having  been  consid- 
ered as  merely  a  local  affection,  and  only  local  means  having 
been  applied  for  its  relief. 

In  the  treatment  of  pruritus  ani  it  is  well  to  avoid  the 
internal  administration  of  opium  in  any  form;  you  may  pro- 
cure a  night's  rest  by  its  use,  but  you  pay  dearly  for  it  after- 
wards, in  an  increase  of  the  disorder.  When  the  irritation 
is  so  great  that  the  patient  is  quite  worn  out  for  w^ant  of 
rest,  I  have  for  years  past  recommended  the  introduction 
into  the  anus  at  bedtime  of  a  bone  plug,  shaped  like  the 
nipple  of  an  infant's  feeding-bottle,  with  a  circular  shield  to 
prevent  it  from  slipping  into  the  bowel;  the  nipple  should  be 
about  an  inch  and  a  half  in  length  and  as  thick  as  the  end 
of  the  forefinger.  This  is  most  efficient  in  preventing  the 
nocturnal  itching;  a  good  night's  rest  is  almost  sure  to  result 
from  its  use,  but  I  advise  it  to  be  worn  only  every  other 
night.  I  presume  that  it  benefits  by  exercising  pressure 
upon  the  venous  plexus  and  filaments  of  nerves  close  to  the 
anus.  The  idea  of  this  plug  occurred  to  me  from  several  of 
my  patients  telling  me  that  the  only  way  they  could  obtain 
relief  and  sleep,  when  the  itching  was  very  bad,  was  by 
introducing  the  end  of  the  forefinger  into  the  anus,  and 
making  pressure;  this  instantly  arrested  the  irritation. 

When  pruritus  is  accompanied  by  internal  haemorrhoids, 
their  removal  almost   always  cures  the  itching;  this  result 


PRURITUS    ANI.  143 

was  well  shown  ii>  a  very  bad  case  operated  upon  by  me  in 
the  practice  of  Mr.  Gervis,  of  Haverstock  Hill.  The  irrita- 
tion had  been  present  for  a  long  while,  and  it  had  resisted 
all  kinds  of  treatment,  but  yielded  when  the  piles  were  got 
rid  of. 

Pruritus  caused  by  a  parasitic  vegetable  growth  is  readily 
cured  by  the  application  of  sulphur  ointment;  or,  what  is 
much  cleaner,  and  equally  efficacious,  a  lotion  of  sulphurous 
acid  of  the  strength  of  one  part  to  six  of  water. 

I  had  soma  time  ago,  in  an  adult,  a  very  obstinate  case  of 
anal  irritation,  caused  by  ascarides.  I  really  did  not  expect 
these  to  be  the  origin  of  the  malady,  but  I  happened  to  see 
one  of  the  worms  just  at  the  orifice;  a  brisk  purge,  and  a 
few  injections  of  solution  of  iron  freed  the  patient  of  the 
parasites  and  the  pruritus  also.  It  always  well  to  bear  in 
mind  the  possibility  of  these  causes  of  the  disorder. 


CHAPTER  XV. 

FISSURE    AND    PAINFUL    IRRITABLE    ULCER    OF    THE  RECTUM. 

This  is  an  excessively  painful  and  by  no  means  uncommon 
affection;  it  is  more  frequently  found  in  women  than  in 
men,  although  not  rare  in  the  latter.  I  have  seen  fissure  in 
a  baby  in  arms,  and  in  a  old  woman  of  eighty,  in  whom  it 
was  associated  with  ^n  impaction.  By  far  the  most  usual 
position  of  fissure  is  dorsal  or  nearly  dorsal,  although  it  may 
be  anterior  or  lateral.  It  may  be  brought  about  by  an 
injury  or  tearing  of  the  mucous  membrane  at  the  verge  of 
the  anus;  it  may  therefore  be  caused  by  straining,  or  by  the 
passage  of  very  dry,  hard  motions;  sometimes  it  follows 
severe  diarrhoea;  it  is  frequently  the  sequel  of  a  confinement, 
and  the  accompaniment,  and  occasional  result,  of  polypus. 
The  origin  of  many  fissures  is  syphilis. 

As  a  rule  patients  suffering  from  fissure  of  the  rectum 
imagine  that  their  symptoms  are  due  to  haemorrhoids;  they 
tell  you  that  they  have  a  discharge  of  blood  and  matter,  a 
swelling  outside  the  bowel,  and  pain  at  stool,  and  they 
believe  they  have  piles.  Unfortunately,  not  infrequently 
the  medical  attendant  is  satisfied  with  the  patient's  diagnosis, 
and  treats  the  case  as  one  of  external  haemorrhoids* 


144  FISSURE    AND    PAINFUL 

I  should  say  generally  that  when  a  patient  complains  of 
great  pain  on  defecation,  it  is  not  piles  that  he  is  suffering 
from,  and  certainly  not  uncomplicated  piles. 

In  fissure  the  pain  on  the  bowels  acting  is  more  or  less 
acute;  some  describe  it  as  like  tearing  open  a  wound,  and 
doubtless  it  is  of  very  excruciating  character.  I  have  known 
patients  who  for  hours  could  not  bear  to  stir  from  one  posi- 
tion, the  least  movement  causing  an  exacerbation  of  the 
pain.  This  agony  induces  the  sufferer  to  postpone  reUeving 
the  bowels  as  long  as  possible,  the  result  being  that  the 
motion  becomes  desiccated  and  hardened,  and  inflicts  more 
grievous  pain  when  at  last  it  has  to  be  discharged.  After 
action  of  the  bowels,  the  pain  may  in  a  short  time  entirely 
cease,  and  not  return  at  all  until  another  evacuation  takes 
place,  but  often  it  continues  very  severe  and  of  a  burning 
character,  or  it  is  of  a  dull,  heavy  character,  and  accom- 
panied by  throbbing,  which  lasts  for  hours,  sometimes  even 
all  day,  so  that  the  patient  is  obliged  to  lie  down,  and  is 
utterly  incapable  of  attending  to  any  business.  In  some 
instances  the  pain  does  not  set  in  until  a  quarter  or  half  an 
hour  after  the  bowels  have  acted. 

In  children  and  young  persons,  unless  a  polypus  com- 
plicates the  fissure,  I  think  it  is  almost  always  curable  without 
operation.    I  have  had  many  cases  resembling  the  following. 

A  child,  aet.  4^,  admitted  into  St.  Mark's,  September, 
1867.  For  twelve  months  or  more  he  has  been  subject  to 
procidentia  every  time  his  bowels  acted;  he  is  usually  rather 
constipated.  About  five  or  six  months  ago  he  began  to 
suffer  pain,  which  lasted  for  hours  after  the  bowels  had  been 
relieved;  this  was  so  severe  that  he  screamed  and  rolled 
about  in  his  bed;  he  often  passed  a  little  blood;  the  pain 
was  much  aggravated  when  he  was  costive.  On  an  injection 
being  given,  the  rectum  came  down,  and  a  very  distinct 
fissure  with  a  papillary  growth  at  its  commencement  was 
seen.  There  was  no  polypus  in  the  bowel;  Ung.  Zinci  with 
extract  of  belladonna  and  opium  was  ordered  to  be  used 
night  and  morning,  and  confection  of  senna  with  sulphur  to 
be  taken  to  keep  the  bowels  gently  acting.  This  prescription 
afforded  immediate  relief;  in  three  weeks  the  ulcer  was 
healed  and  the  child  perfectly  cured. 

In  children  suffering  from  hereditary  syphilis,  numerous 
small  cracks  round  the  anus  are  common,  and  they  cause 
much  pain.  Mercurial  applications  and  extreme  cleanli- 
ness soon  cure  them,  but  they  will  return  from  time  to  time 


IRRITABLE    ULCER    OF    THE    RECTUM.  145 

unless  anti-syphilitic  medicines  be  taken  for  a  lengthened 
period. 

Fissure,  although  really  so  simple  a  matter,  and  its  cure 
generally  so  easy,  wears  out  the  patient's  health  and 
strength  in  a  remarkable  manner;  the  constant  pain  and 
irritation  to  the  nervous  system  are  more  than  most  persons 
can  bear;  I  have  frequently  seen  women  suffering  from  small 
anal  ulcer, who  thought  they  must  have  cancer,  in  consequence 
of  their  extreme  illness  and  pain.  What  under  these  circum- 
stances is  very  extraordinary  is  the  length  of  time  people  go 
on  enduring  the  malady  without  having  anything  done  for 
it.  It  is  not  an  uncommon  thing  for  one  to  see  fissures  of 
many  years'  duration,  especially  in  young  women,  who, 
through  delicacy  of  feeling,  often  conceal  rectal  affections. 

It  is  common  for  fissures  to  heal  for  a  time  and  then 
break  out  again,  so  patients  are  apt  to  think  a  perfect  cure 
will  result,  and  defer  proper  treatment. 

The  usual  position  on  the  side  is  the  best  for  making  an 
examination.  Let  the  patient  raise  the  upper  buttock  with 
the  hand,  then  with  your  fore-finger  and  thumb  gently  open 
the  anus,  at  the  same  moment  telling  the  patient  to  strain 
down;  you  will  then  be  able  to  see,  just  within  the  orifice,  an 
elongated,  club-shaped  ulcer;  the  floor  of  it  may  be  very  red 
and  inflamed,  or,  if  the  ulcer  is  of  long  standing,  of  a  grey- 
ish color  with  the  edges  well  defined  and  hard. 

Frequently  the  sight  of  the  fissure  is  marked  externally 
by  a  small  clavate  papilla  or  minute  muco-cutaneous  poly- 
poid growth;  this  must  not  be  confounded  with  ordinary 
polypus,  and  it  is  not  the  cause  of  the  fissure,  but  the  result 
of  the  local  irritation  and  inflammation  which  have  been 
going  on.  Sometimes  the  situation  of  the  fissure  is  indica- 
ted by  an  inflamed  and  swollen  piece  of  skin,  and  in  this 
case  ulceration  through  the  portion  of  the  integurr^ent  not 
infrequently  occurs,  and  a  small  but  extremely  painful  fistula 
results.  In  such  a  case  very  probably  a  small  abscess  had 
formed  just  above  the  external  sphincter,  and  had  burrowed 
under  it,  making  in  time  a  complete  fistula.  These  small 
abscesses  are  very  painful.  It  occurred  to  me  to  observe 
this  in  the  wife  of  a  medical  man.  When  I  first  examined 
her  I  found  she  had  well-marked  fissure  and  an  inflamed 
piece  of  skin  close  to  the  anus.  I  predicted  that  the  ulcer- 
ation would  perforate  this,  and  so  it  did,  for  in-  about  ten 
days,  when  I  went  to  operate  upon  her,  I  found  a  small 
fistula  had  formed. 


146  FISSURE    AND    PAINFUL 

Occasionally,  on  proceeding  to  examine  a  patient,  the  first 
thing  you  see  is  the  small  club-shaped  papilla  I  have  already 
mentioned  protruding  from  the  anus;  you  may  then  be  certain 
that  an  ulcer  exists.  I  may  here  mention  that  when  operat- 
ing, this  growth  ought  to  be  snipped  off,  or  the  case  may  not 
do  well,  as  it  falls  down  into  the  wound  and  retards  or  quite 
prevents  healing. 

Fissure  is  very  commonly  associated  with  uterine  displace- 
ment. I  have  stated  that  of)erations  upon  haemorrhoids 
under  similar  conditions  are  not  satisfactory;  the  same 
observation  applies  with  quite  as  much  truth  to  fissure  and 
uterine  disease.  I  have  many  times  had  reasons  to  repent 
interfering  with  these  cases.  The  successful  treatment  of 
the  uterine  disorder  may  be  sufficient  to  cure  the  fissure  (if 
no  polypus  exists),  or  at  all  events  the  ulcer  will  afterwards 
yield  to  local  applications  and  general  treatment.  If  the 
fissure  should  be  benefited  by  operation,  as  long  as  the 
uterine  malady  exists  there  will  be  a  constant  danger  of  a 
relapse  taking  place.  The  most  common  forms  of  uterine 
displacement  in  connection  with  fissure  are,  according  to 
my  experience,  anteversion  and  retroversion,  and  associated 
with  these  I  have  frequently  observed  affections  of  the  blad- 
der, chronic  cystitis,  and  spasmodic  pains  in  micturition. 
When  you  find  these  three  disorders  united,  depend  upon  it 
you  will  have  a  case  that  will  call  for  all  your  skill  and 
patience  to  bring  to  a  successful  issue. 

Gelatinous  and  fibrous  polypi  are  not  at  all  uncommon 
complications  of  fissure.  The  polypus  is  usually  situated  at 
the  upper  or  internal  end  of  the  fissure,  but  it  may  be  on  the 
opposite  side  of  the  rectum.     Here  is  a  case: 

Mary  G ;  aet.  47,.  was  admitted  into  St.  Mark's,  April, 

187 1.  She  had  a  well-marked  and  very  painful  fissure  near 
the  anus.  There  was  no  polypus  to  be  seen,  but  on  passing 
my  finger  into  the  rectum  I  found  a  pedunculated  fleshy 
polypus  on  the  opposite  side  of  the  bowel  to  that  on  which 
the  fissure  was  situated.  I  am  quite  confident  that  had  I 
incised  the  fissure  and  left  the  polypus  this  patient  would 
not  have  recovered. 

If  you  do  not  remove  a  polypus  at  the  time  you  divide 
the  ulcer,  failure  is  certain  to  result,  as  I  have  myself  seen 
many  times. 

If  the  fissure  is  of  recent  origin  it  may  often  be  cured 
without  operation,  especially  if  it  be  situated  anteriorly.  In 
women  this  can  almost  certainly  be  accomplished.     Of  all 


IRRITABLE    ULCER   OF    THE    RECTUM.  147 

the  varieties  of  fissure  the  syphilitic  is  most  amenable  to. 
general  treatment;  when  of  syphilitic  origin  they  are  often 
multiple.  I  have  noticed  three  distinct,  mell-marked  fissures 
in  one  patient.  I  have  seen,  in  the  practice  of  my  colleagues 
at  St.  Mark's,  many  instances  of  multiple  fissure.  I  may 
here  mention  that  if  you  are  obliged  to  operate  upon  a 
multiple  fissure  one  incision  through  the  sphincter  will  be 
sufficient. 

Now  as  to  the  treatment.  In  all  cases,  rest  in  the  recum- 
bent position  should,  as  much  as  possible,  be  adopted. 
Mild  laxatives  should  be  given,  not  to  purge,  but  to  keep 
the  bowels  acting  once  daily;  this  may  sometimes  be  effected 
by  diet  alone.  The  domestic  remedy  of  figs  soaked  in  sweet 
oil,  or  onions  and  milk  at  bedtime,  may  be  sufficient.  I 
often  order  a  combination  of  equal  parts  of  the  confection 
of  sulphur  and  confection  of  senna;  small  doses  of  sulphate 
of  magnesia  or  sulphate  of  potash,  half  a  tumbler  of  Pullna  or 
Friedrichshall  water  taken  in  the  morning  fasting,  the  com- 
pound liquorice  powder  of  the  German  pharmacopoeia,  and  the 
liquid  extract  of  the  Rhamnus  frangula,  are  great  favorites 
of  mine. 

You  must  be  prepared  to  alternate  the  medicines  as  one  or 
other  seems  to  lose  its  effect.  All  drastic  purges  should  be 
avoided,  but  I  do  not  object  to  small  doses  of  the  aqueous 
extract  of  aloes,  especially  when  combined  with  nux  vomica 
and  iron.  It  will  be  an  advantage  if  the  patient  can  manage 
to  get  the  bowels  to  act  the  last  thing  at  night  instead  of  in 
the  morning,  as  the  rest  is  very  beneficial  and  the  pain  does 
not  continue  so  long  when  lying  down.  After  the  action 
3  ss  of  Liq.  Opii  sedativus  may  be  injected  with  3  ij  of 
cold  starch;  this  is  especially  valuable  if  the  patient  has  the 
bowels  relieved  at  bedtime.  As  an  application,  I  know 
nothing  better  than  the  following  ointment : — 

]^ .     Hydrarg.  Sub-chloridi gr.  iv 

Pulv.  Opii gr.  ij 

Ext.  Belladonnae gr.  ij 

Unguent.  Sambuci 3  j.     M. 

To  be  applied  frequently. 

I  have  effected  many  cures  with  this  ointment  alone.  An 
occasional  very  light  touch  with  the  nitrate  of  silver  (not  to 
cauterise  but  to  sheathe  the  part  with  an  albuminate  of  sil- 
ver) is  useful,  and  it  relieves  pain  for  some  time.  If  there 
be  very  great  spasm  of  the  sphincter,  extract  of  belladonna 


148  FISSURE    AND    PAINFUL 

may  be  thickly  smeared  around  the  anus  over  the  muscle, 
and  this  I  have  at  times  found  effective.  If  ointments  do 
not  agree  with  the  sore,  lotions  maybe  preferable;  Goulard 
water  with  opiates  and  sedatives  may  afford  some  temporary 
relief,  but  one  must  acknowledge  that  the  best  devised  and 
most  carefully  carried  out  general  treatment  frequently  fails, 
save  in  favorable  cases. 

In  my  opinion,  if  the  base  of  the  ulcer  be  gray  and  hard, 
and  if  on  passing  the  finger  into  the  bowel  you  find  the 
sphincter  hypertrophic  and  spasmodically  contracted,  feel- 
ing, as  it  often  does,  Hke  a  strong  india-rubber  band,  with  its 
upper  edge  sharply  and  hardly  defined,  nothing  but  the 
adoption  of  such  means  as  will  utterly  and  entirely  prevent 
all  action  of  the  muscle  for  a  greater  or  less  length  of  time, 
is  likely  to  effect  a  cure  of  the  fissure. 

Some  authors  specify  the  time  at  which  this  disease  may 
be  curable  without  operation,  and  say,  "  If  it  has  existed 
more  than  three  months  the  attempt  is  hopeless;"  but  really 
the  time  is  not  of  importance;  the  question  is,  what  patho- 
logical changes  have  been  brought  about  ?  I  have  cured 
fissure  of  months'  standing  when  there  was  no  great  hyper- 
trophy of  the  muscles.     Here  are  some  cases: 

Mrs.  E ,  aet.  24,  was  sent  to  me  by  Dr.  Simpson,  of  the 

Old  Kent  Road.  Five  months  ago  she  was  confined  with 
her  first  child  after  a  somewhat  lingering  labor.  .  The  first 
time  the  bowels  acted  she  had  pain;  and  ever  since  then  she 
has  never  had  an  action  without  suffering.  This  has  been 
gradually  increasing,  and  now  her  life  is  almost  unendura- 
ble; the  pain  lasting  for  hours,  and  compelling  her  to  lie 
down,  so  that  she  is  quite  unable  to  attend  to  her  household 
duties.  On  examination  a  very  characteristic  dorsal  fissure 
was  seen;  there  was  no  polypus  or  piles.  The  rectum  was 
generally  healthy,  and  there  was  not  very  marked  spasm  or 
thickening  of  the  sphincter.     The  bowels  were  confined. 

Ordered: — 

5- .     Magnes,   Sulph 3  j 

Ferri  Sulph gr.  j 

.  Acid  Sulph.  dilut Mv 

Inf.  Quassise |  j      M. 

Ter  die. 
And  to  use  the  following  ointment: — 


IRRITABLE    ULCER    OF    THE    RECTUM.  I49 

1^ .     Ung.  Hydrarg.  subchlor 3  j 

^     Ext.  Opii 

Ext.  Belladonnas aa gr.  iij  M. 

To  be  applied  after  action  of  the  bowels  and  also  at 
night. 

I  touched  the  ulcer  every  other  day  with  a  solution  of 
perchloride  of  mercury.  In  a  fortnight  the  fissure  was 
nearly  healed,  and  she  had  scarcely  any  pain  after  defeca- 
tion.    Soon  after  this  I  heard  she  had  got  quite  well. 

A  city  dignitary  consulted  me  some  time  back,  on  the 
recommendation  of  Dr.  Sedgwick  Saunders.  His  history 
was  that  for  eighteen  months  or  more  he  had  suffered  pain 
on  defecation;  at  times  he  was  much  better  and  only  experi- 
enced uneasiness,  and  then  again  the  pain  returned  as  bad  as 
ever.  Homoeopathy  had  been  tried  for  some  six  or  seven 
months,  and  he  had  derived  benefit  as  far  as  his  constipation 
was  concerned,  but  the  pain  was  no  better.  He  had  culti- 
vated the  habit  of  getting  his  bowels  to  act  about  six  o'clock 
in  the  morning,  so  that  afterwards  he  could  return  to  bed 
and  lie  quiet  for  a  couple  of  hours;  he  was  then  able  to  get 
up  and  come  to  town  by  train  without  suffering  much;  but 
if  he  had  to  travel  soon  after  visiting  the  water-closet  he  was 
in  pain  all  day.  He  was  very  careful  in  his  diet,  drank  very 
little  wine  and  was  accustomed  to  take  oatmeal  porridge, 
brown  bread,  fruits,  and  vegetables,  which  I  dare  say  had 
more  effect  on  his  bowels  than  the  globules  of  nux  vomica 
to  which  he  attributed  his  regularity.  As  he  laid  very  much 
stress  upon  the  use  of  these  globules,  and  was  strongly  of 
opinion  that  he  would  have  no  action  without  them,  I  did 
not  oppose  their  continuance,  knowing,  as  I  well  do,  how 
much  the  belief  that  a  certain  drug  is  beneficial  tends  to 
make  it  so.  On  examining  this  patient  I  found  a  small,  cir- 
cular,  perineal  ulcer  situated  at  the  upper  edge  of  the  exter- 
nal sphincter;  it  was  clean  cut  and  inflamed.  The  rectum 
was  otherwise  healthy,  and  the  sphincter  was  not  much 
hypertrophied.  Taking  into  consideration  the  length  of  time 
the  ulcer  had  existed,  I  advised  incision,  but  that  he  would 
not  listen  to,  so  I  prescribed  my  usual  ointment,  but  was 
speedily  obliged  to  leave  out  the  extract  of  belladonna,  as 
he  was  so  sensitive  to  the  action  of  this  drug  as  to  get  dry 
mouth  and  dilated  pupils  with  affected  vision,  in  twenty-four 
hours  after  applying  it.  After  three  weeks  I  found  the  ulcer 
was  not  any  better,  although  I  had  varied  my  treatment, 


150  FISSURE    AND    PAINFUL 

touched  it  with  nitrate  of  silver,  perchloride  of  mercury, 
etc.;  he  had  also  used  lotions  of  the  tartrate  and  persulphate 
of  iron.  I  had  observed  that  there  was  one  minute  spot 
most  excessively  tender,  much  more  so  than  the  rest  of  the 
sore.  There,  no  doubt,  was  an  exposed  nerve;  so  I  took  a 
hint  from  the  late  Mr.  Hilton's  work  on  "  Rest  and  Pain," 
and  applied,  once,  some  acid  nitrate  of  mercury.  From 
that  day  the  ulcer  rapidly  healed,  and  soon  this  gentleman 
got  perfectly  well;  I  know  that  he  continues  so  to  this  day. 

I  may  here  remark  that  I  have  several  times  had  a  similar 
success  from  the  fuming  nitric  acid,  but  I  prefer  the  acid 
nitrate  of  mercury.  I  have  had  very  good  results  from  a 
suppository  of  oxide  of  mercury. 

A  lad.  aet.  19,  came  to  me  at  St,  Mark's  with  double  fissure; 
both  the  ulcers  were  very  well  marked,  and  there  was  one  on 
either  side  of  the  anus.  He  suffered  the  greatest  pain  for 
hours  after  defecation.  On  examining  him  I  found  that  he 
had  a  syphilitic  rash,  squamous  and  coppery;  his  tonsils 
were  ulcerated,  and  he  had  also  enlarged  and  hardened 
glands  in  his  groin.  He  admitted  that  he  had  suffered  from 
a  sore  on  his  penis,  and  had  been  treated  for  it  at  St.  Bar- 
tholomew's Hospital  ;  he  did  not  know  whether  he  had 
taken  mercury  or  not.  The  sore  on  the  penis  had  been  well 
about  five  months  and  the  pain  on  going  to  stool  had  existed 
for  four  months.  The  rectum  was  healthy,  and  there  were 
no  mucous  tubercles.  I  put  him  on  a  course  of  bichloride 
of  mercury  and  tonics,  as  he  was  much  out  of  health  ;  he 
took  the  hospital  confection  to  keep  his  bowels  gently  act- 
ing, and  used  strong  calomel  ointment  with  powdered  opium; 
after  three  weeks'  treatment  the  fissures  had  quite  healed,  so 
then  he  ceased  to  attend,  although  his  syphilitic  symptoms 
had  not  disappeared. 

I  have  headed  this  chapter  "  Fissure  and  painful  irritable 
ulcer"  because  the  symptoms  and  treatment  do  not  differ, 
whatever  form  the  ulcer  assumes,  whether  it  be  elongated  and 
club-shaped,  oval,  or  circular  but  as  a  rule  the  small  circu- 
lar ulcer  is  situated  higher  up  the  bowel  than  fissures,  are 
which  generally  extend  to  the  junction  of  the  mucous  mem- 
brane with  the  skin  ;  the  ulcer  being  more  commonly  found 
above  or  about  the  lower  edge  of  the  internal  sphincter  ani. 
I  think  also  that  in  the  circular  ulcer  there  is  less  severe  pain 
at  the  moment  of  defecation  but  it  comes  on  from  five  min- 
utes to  a  quarter  or  half  an  hour  after  that  act,  and  then  is 
quite  as  intolerable  as  that  resulting  from  the  fissure.  These 


IRRITABLE    ULCER    OF    THE    RECTUM.  15  X 

minute  ulcers  are  more  difficult  to  find  than  the  fissures,  as 
thfey  often  cannot  be  seen  without  the  use  of  a  speculum, 
or  getting  the  patients  to  strain  violently;  which  they  will  not 
do  for  fear  of  exciting  pain  ;  in  fact  they  generally  draw  up 
the  anus  as  much  as  they  can  when  you  are  examining  them. 

An  educated  finger  detects  these  ulcers  directly;  they  feel 
much  like  the  internal  aperture  of  a  fistula,  but  the  edges 
are  harder'  and  therefore  more  defined  ;  and  there  is  no 
elevation  above  the  surface  of  the  surrounding  mucous 
membrane  as  if  frequently  the  cas.e  in  fistula.  These  ulcers 
often  borrow  and  then  they  become  the  internal  openings  of 
blind  internal  fistulae. 

There  has  often  been  a  controversy  at  times  as  to  the 
depth  of  incision  necessary  to  cure  a  fissure,  some  advocating 
a  slight  cut  and  others  a  free  one.  There  is  no  doubt  that 
in  some  cases  a  very  superficial  incision  through  the  base  of 
the  fissure,  so  as  to  divide  the  fibres  of  the  muscles  immedi- 
ately beneath  the  ulcer  or  even  to  cut  through  an  inflamed 
filament  of  nerve,  may  be  enough  ;  but  on  the  other  hand, 
I  have  frequently  seen  slight  incisions  fail,  and  I  am  confi- 
dent that  a  tolerably  free  one,  sufficient  to  secure  the  relaxa- 
tion of  the  sphincter,  and  put  the  parts  entirely  at  rest,  is  by 
far  the  safer  plan  ;  and  this  indeed,  is  the  physiological 
reason  of  the  success  attending  the  operation. 

I  do  not  mean  by  this  that  you  need  cut  right  through  both 
sphincters  into  the  cellular  space  beneath,  as  the  older  sur- 
geons used  to  do,  but  I  am  sure  that  a  fairly  free  incision 
heals  quite  as  quickly  as  a  small  one,  and  that  it  is  much 
better  to  cut  rather  too  deeply  than  too  superficially. 

Those  who  are  in  favor  of  a  slight  cut  say  that  inconti- 
nence of  faeces  may  be  brought  about  by  too  free  an  incision 
through  the  muscles.  That  may  be  the  case  when  the  cut 
is  not  properly  made,  /.  e.,  when  the  mescles  are  not  cut  at 
right  angles  to  the  direction  of  the  fibres.  An  incision  at 
right  angles  will  join  so  as  to  leave  a  perfect  narrow  scar, 
but  an  oblique  incision  leaves  a  very  weak  wide  scar. 
I  am  quite  certain  that  both  the  internal  and  external  sphinc- 
ter muscles  (on  one  side  only)  may  be  divided  entirely 
in  a  healthy  person,  without  any  danger  of  a  weak  bowel 
following. 

You  maybe  confident  that  your  patient  will  not  readily  par- 
don your  not  curing  him  at  the  first  operation,  and  will  be 
very  disinclined  to  submit  to  a  second  incision  should  the 
first  have  failed.     Most  likely  he  will  take  himself  out  of  your 


152  FISSURE    AND    PAINFUL 

hands,  and  seek  other  advice  ;  it  has  occurred  to  me  to  have 
to  operate  upon  patients  both  hospital  and  private,  where 
eminent  surgeons  had  failed  to  effect  a' cure,  and  I  have 
found  that  failure  had  resulted  from  one  of  two  causes  either 
the  too  sparing  use  of  the  knife,  or  the  overlooking  of  a 
polypus. 

When  operating,  if  not  very  au  fait  at  rectal  surgery,  I 
should  advise  you  to  introduce  a  speculum  ;  you  then  see 
exactly  where  your  knife  should  go,  and  the  parts  are  also 
rendered  tense,  so  that  their  division  is  facilitated  ;  the  incis- 
ion should  commence  a  little  above  the  upper  end  of  the 
fissure,  and  terminate  a  little  beyond  the  outer  end,  so  that 
the  whole  sore  is  cut  through  ;  as  a  general  rule  the  depth  of 
incision  should  not  be  less  than  a  quarter  of  an  inch.  If  the 
outer  end  of  the  fissure  be  marked  by  a  swollen,  inflamed 
piece  of  skin,  it  is  better  to  remove  that  with  a  pair  of  scissors 
for  by  so  doing  the  healing  process  is  greatly  expedited;  the 
small  polypoid  growth  also,  so  frequently  found  in  fissure, 
should  at  the  same  time  be  snipped  off.  Please  to  note 
that  I  am  not  recommending  the  cutting  off  of  true  rectal 
polypi. 

It  has  been  suggested  that  a  curved  bistoury  may  be  passed 
beneath  the  ulcer,  and  the  ciit  made  from  beneath  toward  the 
bowel.  I  do  not  see  any  advantage  in  this  mode  of  operating 
for  my  own  part,  I  always  insert  my  forefinger  into  the 
bowel,  feel  the  situation  of  the  fissure,  pass  upon  my  finger  a 
straight  knife  with  a  rounded  point,  then  turn  the  edge  to 
the  base  of  the  ulcer  and  make  the  incision  ;  or,  the  knife- 
blade  can  be  laid  flat  upon  the  forefinger  and  both  intro- 
duced together  into  the  bowel,  and  the  cut  then  made  ;  this 
is  a  good  plan  where  there  is  much  spasm  of  the  sphincter. 
When  the  fissure  is  quite  dorsal,  the  cut  should  be  made  not 
directly  through  it  but  somewhat  laterally,  by  which  means 
you  are  certain  of  completely  dividing  the  fibres  of  the  mus- 
cle and  the  wound  will  heal  more  readily.  A  small  piece 
of  cotton  wool  may  be  placed  in  the  wound  and  allowed  to 
remain  for  twenty-four  or  forty- eight  hours.  It  is  well 
to  keep  the  bowel  confined  for  two  or  three  days. 

Usually  there  is  no  occasion  for  the  patient  to  beep  in  bed 
but  it  is  advisable  that  much  exercise  or  standing  about 
should  be  interdicted  ;  a  few  days'  rest  on  the  sofa  is  in  sim- 
ple cases,  all  that  is  required.  The  reverse  of  all  this  is 
absolutely  necessary  when  there  is  any  uterine  complication  ; 
the  patient  here  must  be  kept  entirely  at  rest  and  lying  down 


IRRITABLE    ULCER    OF    THE    RECTUM.  1 53 

until  the  wound  has  soundly  healed,  for  most,  assuredly,  if 
she  gets  about  too  soon,  either  the  wound  will  not  close,  or  a 
worse  result,  viz.,  unhealthy  ulceration  will  ensue.  I  have 
seen  many  cases  showing  the  good  policy  of  long-continued 
rest,  and  numbers  more  where  bad  result  have  followed  a 
speedy  resumption  of  ordinary  duties  ;  on  this  point  I  could 
relate  numerous  illustrative  cases,  but  one  shall  suffice. 

Ada  T was  admitted  into  St.  Mark's  Hospital  August, 

1866;  she  was  twenty-four  years  of  age,  was  married,  and 
had  five  children;  she  was  in  the  hospital  three  months  ago, 
and  was  operated  upon  by  Mr.  Lane,  for  fissure;  she  left  not 
quite  well.  It  was  noted  on  her  card  that  she  suffered  from 
retroversion,  and  had  an  enlarged  uterus.  On  examining 
her,  on  her  re-admission,  rather  extensive  but  superficial 
ulceration  was  found  to  have  taken  place  since  her  going 
out.  The  ulceration  extended  above  the  upper  edge  of  the 
internal  sphincter.  She  had  a  good  deal  of  pain  and  fre- 
quent harassing  diarrhoea.  There  was  no  history  or  sign  of 
syphilis.  After  three  months'  treatment  by  injections,  seda- 
tive and  astringent,  and  the  internal  administration  of  iodide 
of  potassium  and  tonics,  she  was  discharged  cured.  The 
uterus  was  kept  in  its  place  by  means  of  a  Hodge's  pessary. 

These  fissures,  or  irritable  ulcers,  not  very  uncommonly 
give  rise  to  a  train  of  nervous  aid  hypochondriacal  sensa- 
tions,  which  continue  even  after  the  ulcer  itself  has  healed. 
I  have  seen  examples  of  this  in  both  hospital  and  private 
practice,  and  both  in  men  and  women. 

An  elderly  maiden  lady  has  been  seen  by  me  at  various 
times  for  the  last  four  or  five  years,  her  history  being  that, 
fully  five  years  back,  she  had  a  small  painful  ulcer  situated 
over  the  upper  part  of  the  internal  sphincter  muscle,  which 
was  much  hypertrophied  and  spasmodically  contracted.  A 
limited  division  of  the  muscle  failed  to  effect  a  cure,  and 
after  six  months'  trial  to  get  the  ulcer  to  heal  I  again  ope- 
rated, this  time  assisted  by  my  friend  Dr.  Crosby;  I  made  a 
very  free  incision  through  both  muscles,  and  after  that  there 
was  no  difficulty,  the  wound  healed  thoroughly  and  soundly; 
but  ever  since  then,  although  there  is  not  the  slightest  lesion 
of  the  bowel — I  have  often  examined  her  with  both  specu- 
lum and  endoscope  in  the  most  thorough  manner,  to  be  sure 
of  the  fact;  she  frequently,  indeed  almost  constantly,  com- 
plains of  her  old  pain.  There  is  a  burning  uneasy  sensation 
in  the  bowel,  but  no  local  tenderness  to  touch.  She  cannot 
walk  about  much,  nor  sit  long  in  one  position,  nor  ride  far 


154  FISSURE    AND    PAINFUL 

in  any  vehicle  without  suffering.  She  is  stout,  looks  well, 
and  her  general  health  has  not  suffered.  There  is  no  dis- 
charge of  any  kind,  mucous,  purulent  or  bloody;  and,  as  a 
rule,  she  does  not  have  pain  on  defecation.  There  is  no 
abnormal  redness  or  heat  of  the  bowel,  although  she  always 
has  the  sensation  of  great  heat  in  the  part.  She  has  no  uter- 
ine affection  (two  eminent  obstetric  physicians  have  exam- 
ined her,  and  say  so),  and  she  has  ceased  menstruating  some 
years. 

Now,  what  is  the  matter  with  this  patient  ?  Some  may 
call  it  neuralgia  or  hysteria;  but  it  has  resisted  all  the  usual 
remedies  prescribed  for  these  complaints,  including  hypo- 
dermic injections  of  morphia  and  quinine;  in  fact,  she  has 
taken  all  kind  of  remedies  prescribed  by  other  medical  men 
as  well  as  myself.  I  have  two  ideas  as  to  the  cause  of  suf- 
fering in  this  case:  The  first  is,  that  it  is  possible  that  some 
filament  of  nerve  is  included  in  the  cicatrix  of  the  wound, 
and  thus  irritation  or  inflammation  is  kept  up,  as  one  sees 
occasionally  after  amputations  of  the  extremities;  the  second 
idea  is,  that  her  mind  has  been  dwelling  for  so  long  a  time 
on  the  state  of  her  bowel  that,  although  now  there  is  nothing 
organically  the  matter  with  her,  she  retains  the  power,  by 
mental  concentration,  of  reproducing  the  sensation  of  pain 
in  the  old  spot.  This  may  not  be  the  correct  explanation, 
but  there  is  some  evidence,  I  think,  tending  to  show  that  it 
possibly  is  so;  for  instance,  the  pain  is  not  always  consist- 
ent in  its  behavior;  the  bowels  act  generally  without  pain; 
the  pain  does  not  come  on  directly  after  defecation,  but 
some  hours  after;  sometimes  the  pain  sets  in  before  the 
action,  and  is  removed  or  relieved  by  the  bowel  being  emp- 
tied (a  condition  of  things  quite  inconsistent  with  the  pres- 
ence of  true  ulcer  or  fissure).  Then,  again,  when  the  patient 
is  occupied  pleasantly  or  intently  she  has  no  pain,  but  it  can 
be  produced  immediately  by  excitement  of  a  disagreeable 
kind;  it  is  also  uncertain  in  its  coming  and  going,  as  well  as 
in  its  character;  som.etimes  it  is  smarting,  then  burning,  as 
if  the  rectum  were-  very  hot;  at  another  time  pulsation  is  the 
chief  annoyance,  or  the  bowel  may  feel  quite  plugged  up,  as 
if  the  anus  were  swollen;  and  then  suddenly  the  pain  is  lan- 
cinating, causing  her  to  call  out;  all  this  leads  me  to  think 
that  the  pain  is  mental. 

Whatever  may  be  the*  explanation,  the  fact  is  clear  that 
here  is  a  person  who  has  no  discoverable  lesion  of  structure 
in  a  part,  constantly  suffering  almost  all  the  pain  and  misery 


IRRITABLE    ULCER    OF    THE    RECTUM.  155 

which  was  formerly  induced  by  a  marked  organic  disease. 
This  patient  has  written  to  me  stating  that  she  is  now  quite 
well,  although  nothing  special  has  been  done  for  her.  I 
have  not  related  this  case  because  it  is  unique;  I  have  seen 
others  precisely  similar,  both  in  men  and  women.  I  know 
for  years  I  was  tormented  at  the  hospital  by  a  man,  per- 
fectly healthy  and  strong  looking,  who  used  constantly  to 
attend  the  out-patient  room  complaining  of  a  dreadful  burn- 
ing and  painful  sensation  in  the  rectum  a  little  way  from  the 
anus;  ,he  said  it  kept  him  awake  at  night,  haunted  him  all 
day,  was  never  out  of  his  thoughts,  and  made  his  life  utterly 
miserable.  I  examined  him  many  times  and  could  never 
detect  anything  abnormal  (he  had  been  operated  upon  for 
fissure  years  before  I  saw  him,  by  the  late  Mr.  Salmon); 
there  was  no  redness,  no  discharge,  and  the  thermometer 
showed  no  excessive  heat;  in  fact,  there  was  nothing  to  see 
or  feel.  No  remedy  did  him  any  permanent  good,  but  he 
was  always  a  little  benefited  by  a  fresh  one.  He  used  to 
leave  me  every  now  and  again  and  go  to  one  of  my  col- 
leagues, and  glad  I  was  to  be  quit  of  him,  but  in  a  few 
months  he  was  sure  to  come  back,  and  not  a  whit  better  for 
what  had  been  done  for  him.  I  called  the  malady  hypo- 
chondriasis, but  I  suppose  that  was  only  expressing  by  a 
long  word  that  I  did  not  understand  what  was  the  matter 
with  him.  I  can  emphatically  say  that  such  patients  are 
about  the  most  unsatisfactory  you  can  have. 

Why  are  ulcers  near  the  anus  so  very  painful,  while  those 
situated  higher  up  the  bowel  are  not  generally  so  ?  There 
are  two  reasons  which  suggest  themselves  at  once:  ist,  the 
great  mobility  of  the  external  sphincter;  2d,  the  supply  of 
nerves.  The  lower  part  of  the  rectum  and  the  anus  are  very 
fully  supplied  by  branches  from  the  posterior  and  anterior 
sacral  plexus,  and  more  especially  from  the  pudic.  These 
nerves  send  numerous  branches  between  the  fibres  of  the 
sphincters  and  immediately  beneath  the  mucous  membrane; 
thus  very  superficial  ulceration  exposes  the  nerve,  and  the 
slightest  touch,  contraction,  or  stretching  of  the  sphincter, 
causes  intense  pain. 

If  you  carefully  examine  one  of  these  ulcers  you  will 
usually  find  one  or  more  spots  that  are  most  exquisitely  ten- 
der; this  is  where  the  nerve  is  exposed.  The  lightest  draw- 
ing of  the  knife  across  the  ulcer,  if  done  at  the  right  point, 
will  be  sufficient  to  divide  this  nerve,  and  to  induce  cessation 
of  the  pain  for  some  little  time;  but  the  muscle  beneath 


156  FISSURE    AND    PAINFUL 

being  irritated  and  hypertrophied,  prevents,  by  its  move- 
ments, the  ulcer  from  healing,  and  very  soon  the  pain  will  be 
reestablished;  hence  the  necessity,  in  all  but  the  slightest 
cases,  for  the  division  of  the  sphincter. 

When  the  muscle  is  cut  the  divided  fibres  retract,  and  they 
do  not  unite  so  quickly  as  the  ulcer  heals;  the  result  is  that 
the  muscle,  being  set  quite  at  rest,  soon  loses  its  hypertophy 
and  irritability.  I  have  often  noticed,  after  a  fissure  has 
been  cured,  how  much  reduced  in  size  and  thickness  both 
sphincters  have  become.  The  cause  of  failure  after  imper- 
fect division  of  the  muscle  is,  that  entire  quiet  is  not 
obtained;  the  undivided  fibres,  though  paralyzed  for  a  time, 
soon  recover  themselves,  and  the  old  contraction  is  resumed 
before  the  ulcer  has  had  time  to  heal,  so  that  very  speedily 
it  reassumes  its  former  character. 

A  great  many  apparently  anomalous  symptoms  are  pro- 
duced by  small,  painful  ulcers  of  the  rectum;  retention  of 
urine,  pain  in  the  back,  pain  and  numbness  down  the  back 
of  the  legs,  leading  to  unfounded  fears  of  paralysis,  may  be 
mentioned  as  not  uncommon.  When  in  a  fissure  the  nerves 
are  exposed  the  pain  is  most  acute  at  the  time  of  an  evacua- 
tion; when  they  are  not  so  exposed  the  pain  generally  sets 
in  shortly  after  the  action,  in  consequence  of  the  irritation 
to  the  sphincter.  In  many  of  these  ulcers  an  examination 
with  a  magnifying  glass  has  shown  me  the  fibres  of  the 
external  sphincter  laid  quite  bare.  Patients  sometimes  tell 
you  that  the  first  time  they  suffered  pain  was  after  a  very 
hard  motion,  when  they  felt  something  give  way  with  a 
crack. 

Dr.  Dolbeau,  of  Paris,  considers  the  essence  of  this  disor- 
der to  be  neuralgic,  and  defines  "  fissure  of  the  anus  as  being 
a  spasmodic  neuralgia  of  the  anus,  with  or  without  fissure." 
He  states  that  he  has  seen  cases  where  all  the  intense  pain 
and  agony  of  fissure  were  present,  but  no  structural  lesion 
whatever  could  be  detected.  For  my  own  part  I  cannot 
wholly  subscribe  to  this  view  ;  out  of  the  thousands  of 
patients  who  have  been  under  my  care  suffering  from  rectal 
diseases,  I  have  never  yet  met  with  a  case  in  which  the 
persistent,  regularly  repeated,  intense  pain,  commencing  on 
passing  or  immediately  after  the  passing  a  motion,  which 
distinguishes  fissure,  was  not  associated  with  an  anatomical 
lesion,  though  that  lesion  might  be  very  slight  and  difficult 
to  discover. 

I  have  seen  a  good  many  nervous  patients  who  complained 


IRRITABLE  ULCER  OF  THE  RECTUM.        157 

of  rectal  or  anal  pains,  severe  in  character,  but  still  wanting 
the  essential  characteristics  of  the  pain  of  fissure.  I  have 
also  observed  cases  of  spasmodic  contraction  of  the  sphincter 
inducing  obstinate  constipation  and  attended  with  pain,  but 
not  at  all  strongly  resembling  the  paroxysm  due  to  fissure  ; 
often  a  sudden  spasmodic  acute  stab  seems  to  run  up  the 
bowel  just  before  action,  but  when  the  fecal  mass  is  passed 
a  feeling  of  relief  and  comfort  is  experienced.  I  do  not  say 
that  neuralgia  may  not  coexist  with  fissure,  and  modify  or 
aggravate  the  suffering,  but  I  think  if  it  were  the  essential 
cause  of  the  pain  I  should  be  justified  in  expecting  that  this 
would  occasionally  yield  to  the  internal  exhibition  of  anti- 
neuralgic  remedies,  a  result  which  certainly  is  not  within  the 
range  of  my  knowledge.  I  am  inclined,  but  doubtingly,  to 
express  the  opinion  that  the  one  essential  of  the  malady  in 
its  severest  form  is  an  exposed  nerve,  and  that  the  spasmodic 
contraction  of  the  sphincter,  excited  by  reflex  irritation, 
occasions  the  peculiar  character  of  the  pain. 

Dr.  Dolbeau  is  strongly  in  favor  of  forced  dilatation  of  the 
sphincter,  originated  by  Recamier,  in  the  treatment  of  anal 
fissure  ;  in  fact,  he  scarcely  admits  of  any  other  method.  He 
says  : — 

*'  The  cure  is  thus  complete  after  the  operation,  but  it  is 
not  a  lasting  one,  relapses  often  occurring  ;  this  is  another 
argument  in  favor  of  the  neuralgic  nature  of  the  complaint." 

A  post-mortem  examination  was  made  in  Paris,  on  a  girl 
who  died  of  cholera  within  a  few  hours  of  having  forcible 
dilatation  made  for  the  cure  of  fissure.  The  surgeon  whose 
name  I  have  forgotten,  states  that  none  of  the  fibres  of  the 
sphincter  muscles  were  in  the  least  degree  torn,  though  the 
mucous  membrane  was  slightly  lacerated. 

Although  I  had  in  several  cases  employed  Dr.  Dolbeau's 
method,  I  found,  as  he  had  done,  relapses  were  not  uncom- 
mon, and  I  further  looked  upon  "  forcible  "  dilatation  as  a 
cruel  operation.  My  first  experience  of  this  treatment  was 
gained  in  Paris,  and  I  will  describe  literally  what  I  saw,  and 
it  was  so  repugnant  to  my  feelings  that  I  was  greatly  disin- 
clined to  it.  A  male  patient  was  brought  into  the  theatre 
suffering  from  fissure  of  the  anus.  The  surgeon  introduced 
one  finger  into  the  anus,  and  then  another,  until  he  gradually 
but  with  much  pressure,  got  the  whole  hand  into  the  rectum; 
he  then  made  a  fist  of  his  hand  and  forcibly  drew  it  out.  The 
cries  of  the  patient  were  really  heart-rending,  and  six  or  seven 
assistants  were  employed  in  holding  him  down. 


158  FISSURE    AND    PAINFUL 

Now,  during  the  past  four  years  I  have  repeatedly  dilated 
the  sphincter  for  the  cure  of  fissure,  and  as  I  do  it,  the  opera- 
tion is  not  violent,  and  the  result  is,  on  the  whole,  very  satis- 
factory. The  patient  being  thoroughly  placed  under  the 
influence  of  an  anaesthetic,  I  introduce  my  two  thumbs,  one 
after  the  other,  taking  care  to  press  the  ball  of  one  thumb 
over  the  fissure,  and  the  other  directly  opposite  to  it ;  this 
prevents  the  fissure  from  being  torn  through  and  the  mucous 
membrane  stripped  off.  I  now  gradually  separate  my 
thumbs  ;  then  I  repeat  the  stretching  in  the  opposite  direc- 
tion, /.  ^.,  at  right  angles  to  my  first ;  then  in  other  direc- 
tions, until  I  have  gone  round  the  anus.  I  then  apply  con- 
siderable pressure  to  the  sphincter  muscles  all  round,  pulling 
apart  the  anus  with  four  fingers,  two  on  each  side,  and 
kneading  the  muscles  thoroughly  ;  by  thus  gently  pressing 
and  pulling,  the  sphincters  completely  give  way,  and  the 
muscle,  previously  hard,  feels. like  a  well-beaten  beef-steak, 
or  even  putty.  This  will  occupy  at  least  five  or  six  minutes, 
to  do  thoroughly  ;  there  is  scarcely  more  than  a  drop  or  two 
of  blood  seen,  but  you  can  see  that  the  anus  is  bruised,  and 
for  a  few  days  extravasation  is  noticed,  the  part  gradually 
undergoing  the  changes  of  color  usually  observed  in  any 
bruise.  This  operation  is  perfectly  safe  and  almost  painless. 
I  place  in  the  rectum  a  suppository  of  half  a  grain  of  mor- 
phia and  apply  cold.  I  am  bound  to  say  that  since  I  have 
dilated  as  above  described,  I  have  never  failed  to  cure  a 
patient. 

I  saw,  with  Dr.  Robert  Mitchell,  of  Lewisham,  a  gentle- 
man of  more  than  eighty,  who  suffered  greatly  from  a  fissure 
of  long  standing,  in  conjunction  with  some  haemorrhoids. 
He  was  too  old  to  allow  me  to  press  a  cutting  operation,  but 
dilatation  perfectly  cured  him  in  eight  days,  and  he  has  con- 
tinued in  comfort  until  now. 

I  could  relate  a  number  of  cases  in  which  dilatation  has 
cured  fissure  and  painful  ulcer,  as  well  as  obstinate  constipa- 
tion from  contraction  of  the  sphincter  muscles,  and  in  such 
cases  I  often  employ  it.  I  can  remember  that  the  late  Mr. 
Salmon  was  in  the  habit  of  treating  constipation  by  passing 
bougies,  gradually  increasing  the  size,  until  a  very  large  one 
could  be  introduced  ;  I  have  reason  to  know  he  was  success- 
ful. He  used  the  same  treatment  as  a  preliminary  step  to 
the  operation  on  piles,  and  there,  again,  I  am  sure  he  gained 
much  advantage  in  lessening  the  pain  after  the  operation — 
a  result  which,  as  noticed  in  a  previous  page,  can  be  accom- 


IRRITABLE    ULCER    OF    THE    RECTUM.  I59 

plished  by  dilatation.  There  are  still  cases  of  fissure  and 
ulcer  in  which  I  prefer  the  knife,  and  shall  continue  to  use 
it  ;  but  I  am  bound  fo  say  my  confidence  in  proper  dilatation 
is  greatly  increased,  and  I  am,  sure,  when  properly  done,  it 
is  very  successful,  though  occasional  relapses  may  occur- 
Som.e  years  ago  I  frequently  divided  the  sphincter  subcuta- 
neously  for  the  cure  of  fissure,  but  I  have  ceased  to  practice 
this  operation,  as  possessing  no  advantage  and  not  being  cer- 
tain in  its  results. 


CHAPTER  XVI. 

IMPACTION    OF    F^CES. 

The  result  of  prolonged  constipation  may  be  a  collection 
of  clayey  faeces  formed  in  the  caecum  or  in  any  part  of  the 
colon,  but  the  term  "  impaction  "  is  generally  used  when  the 
accumulation  takes  in  the  pouch  of  the  rectum  immediately 
above  the  internal  sphincter  muscle.  This  is  its  most  fre- 
quent situation,  and  here  a  very  large  deposit,  more  or  less 
globular  in  shape,  is  often  found.  It  occurs  in  females  more 
commonly  than  in  males  ;  old  women,  and  women  shortly 
after  their  confinements,  being  especially  liable  to  it.  In 
aged  people  very  often  one  of  the  first  indications  of  failing 
nerve  power  is  loss  or  diminution  of  the  contractile  force  of 
the  colon  and  consequent  inaction  of  the  bowels,  leading  to 
impaction. 

I  have  seen  some  cases  of  impaction  in  hysterical  young 
girls  and  in  middle-aged  females,  I  have  also  met  with  it 
in  elderly  men,  but  until  recently  I  never  had  a  well-marked 
example  of  this  disorder  in  a  young  man,  but  I  have  found  it 
occur  more  than  once  in  children  ;  I  saw  a  little  boy,  only 
three  years  of  age,  who  had  a  veritable  impaction  which 
gave  a  dood  deal  of  trouble,  but  when  it  was  removed  the 
bowel  soon  regained  it  tone,  and  regular  action  was  afterwards 
easily  kept  up. 

The  cause  of  the  accumulation  I  believe  nearly  always  to 
be,  primarily,  a  loss  of  power  of  the  muscular  coat  of  the 
rectum.  This  loss  of  power  may  have  been  produced  by 
the  pressure  of  the  child's  head,  during  a  long  protracted 
labor,  or  by  over-distention  of  the  bowel  through  habitual 


l6o  IMPACTION    OF    F7ECES. 

neglect  of  the  calls  of  nature,  in  which  case  the  collection 
may  be  the  result  of  months'  costiveness,  and  the  condition 
of  the  rectum  much  resembles  that  of  a  bladder  paralyzed 
from  retention  of  urine. 

Spasm  of  the  sphincter  has  been  said  to  be  a  cause  of 
impaction,  but  I  have  more  often  thought  the  reverse  was 
the  case,  and  the  impaction  the  cause  of  the  spasm.  I  must, 
however,  acknowledge  that  spasm  is  often  the  cause  of  the 
constipation  which  is  the  forerunner  of  impaction.  In  impac- 
tion spasm  of  the  sphincter  always  exists,  in  some  instances 
to  such  a  degree  that  when  the  patient  strained  I  have 
observed  the  anus  protrude  like  a  nipple,  and  an  injection 
return  in  a  fine  stream,  as  if  coming  out  of  a  squirt.  I  have 
certainly  met  with  cases  of  idiopathic  spasm  of  the  sphincter, 
occurring  for  the  most  part  in  elderly,  nervous,  single  women, 
and  though  no  impaction  was  present,  there  was  always  more 
or  less  constipation. 

The  symptoms  of  impaction  are  not  uncommonly  very 
obscure,  and  the  malady  may  be  mistaken  for  something 
else.  I  was  once  call  to  see  a  lady  laboring  under  impac- 
tion, and  found  that  an  eminent  physician  had  recently 
declared  her  to  be  suffering  from  neuralgia  of  the  bowel, 
and  had  ordered  her  quinine  and  steel,  and  I  have  heard  of 
another  case  which  was  treated  as  gout  in  the  rectum.  I 
have  met  with  several  patients  who  were  supposed  to  be  the 
subjects  of  malignant  disease  of  the  caecum  or  sigmoid 
flexure  from  the  fact  of  there  being  a  tumor  present,  and 
from  the  patient's  aspect,  which  is  frequently  very  suggestive 
of  cancer.  I  had  a  very  marked  case  of  impaction  in  a  girl, 
thirteen  years  of  age,  which  was  supposed  to  be  enlarged 
mesenteric  glands,  and  was  being  treated  with  steal  and  cod- 
liver  oil.  I  attended  a  gentleman  who  was  believed  by  his 
physician  to  have  incipient  disease  of  the  brain,  so  much 
nervousness  and  hypochondriasis  resulted  from  a  very  loaded 
colon  and  impacted  rectum.  I  had  a  case  in  a  young  lady 
which  was  said,  by  more  than  one  medical  man,  to  be  phthisis, 
constant  cough  being  present,  with  hectic  at  night,  and  much 
emaciation.  And  lastly,  a  very  common  but  sad  error  is 
often  committed  ;  these  patients  are  treated  for  diarrhoea, 
with  tenesmus,  as  a  considerable  fluid  discharge  from  the 
bowel  is  not  at  all  incompatible  with  great  retention  of  solid 
faeces. 

A  very  interesting  case  was  sent  me  by  Dr.  Frodsham. 
The  patient  was  an  elderlyperson  from  thc'country,  who  was 


IMPACTION   OF   F^CES.  l6l 

placed  under  Dr.  Frodsham's  care.  She  had  been  for  a  long 
time  ill  with  severe  pains  in  the  bowels,  of  a  colicky  charac- 
ter, not  especially  restricted  to  one  part  of  the  abdomen, 
which  was  much  swollen.  No  tumor  could  be  detected. 
She  was  subject  to  hiccough  and  flatulence.  This  was 
attended  with  dyspnoea  and  palpitation  of  the  heart.  She 
had  on  several  occasions  fainted  away,  and  fears  were  enter- 
tained that  the  heart  was  not  sound.  Always,  or  nearly  so, 
in  conjunction  with  the  abdominal  pain  she  had  diarrhoea, 
copious  colored  watery  stools  ;  for  the  correction  of  this  she 
had  been  prescribed  opium  with  carminatives  ;  a  few  doses 
generally  gave  her  much  relief.  Her  appetite  was  bad,  and 
she  had  frequent  retching  and  sometimes  vomiting.  Dr. 
Frodsham  not  being  satisfied  with  the  case  sent  her  to  me. 
She  was  fifty  years  of  age,  not  ill-nourished,  her  face  wore 
an  anxious  expression,  and  the  complexion  was  muddy. 
Her  general  symptoms  had  existed  over  two  years.  The 
tongue  was  quite  clean  and  too  red.  On  examination,  the 
heart  and  lungs  were  found  sound.  The  abdomen  was 
much  distended  and  the  diaphragm  forced  upward,  causing 
dyspnoea  when  she  lay  down.  The  abdomen  was  globular, 
and  there  was  no  particular  prominence  in  any  one  part. 
The  skin  was  not  shiny;  on  manipulation  the  abdomen  felt 
doughy;  it  was  also  tender,  so  that  she  could  not  bear  much 
kneading,  but  after  a  little  pressure  the  transverse  colon 
started  into  action,  and  it  was  felt  to  be  very  large.  A  flex- 
ible tube  was  easily  passed  eighteen  inches,  and  on  with- 
drawal it  was,  in  parts,  smeared  with  faeces;  on  introducing 
the  finger  into  the  rectum  the  latter  was  found  filled  with 
clayey  faeces.  The  diagnosis  was  great  fecal  accumulation 
and  slight  impaction.  I  ordered  her  a  pill  of  podophyllin, 
calomel,  belladonna,  and  pil.  colocynth  co.  three  times  in 
the  day,  and  every  morning  an  injection  of  a  pint  and  a  half 
of  thin  gruel,  with  two  ounces  of  fresh  ox  gall  in  it.  On  the 
third  morning  of  this  treatment  she  passed  an  enormous 
motion,  more  than  enough  to  fill  an  ordinary  chamber  uten- 
sil. The  same  pills  and  enema  were  continued  now  every 
day,  and  were  followed  by  several  enormous  evacuations.  I 
really  may  say  that  the  quantity  of  fecal  matter  she  parted 
with  would,  to  most  persons,  appear  incredible.  After  ten 
days  the  medicine  was  changed  to  a  combination  of  laxa- 
tives and  tonics,  which  she  continued  for  some  time,  but  at 
the  termination  of  three  weeks  all  her  discomforts  were  gone, 
and  she  was  quite  slender,  as  regards  the  abdomen. 


l62  IMPACTION    OF    F^CES. 

In  the  history  of  these  cases  it  is  not  rare  to  find  that 
severe  pains  have  been  experienced  in  the  right  lumbar  and 
left  inguinal  regions;  this  sympton  points  to  the  fact  that  the 
caecum  had  been  the  seat  of  obstruction  and  distention,  and 
that  when  this  was  removed  the  faeces  again  lodged  in  the 
rectal  pouch.  The  symptoms  of  impaction  might  be  expected 
to  be  generally  those  of  obstruction,  and  resemble  in  many 
respects  those  of  stricture  of  the  rectum,  and  sometimes  this 
is  so,  but  the  absence  of  any  jelly-like  or  coffee-ground  dis- 
charge is  an  important  point  to  be  noticed  in  the  diagnosis. 
The  patient  often  really  complains  of  a  tendency  to  diar- 
rhoea, liquid  motions  beingfrequently  passed,  especially  after 
an  aperient,  but  without  any  sense  of  relief,  and  on  assuming 
the  erect  position,  straining,  severe,  continuous  and  irresisti- 
ble, takes  place.  On  lying  down  this  generally  gradually 
passes  off. 

Dyspepsia,  irritability  of  temper,  nervousness  and  dis- 
pondency,  the  patient  supposing  herself  to  be  suffering  from 
an  incurable  malady,  a  very  muddy-yellow  skin,  suggestive 
of  malignant  disease,  morning  vomiting,  and  a  loathing  of 
all  food  as  soon  as  a  few  mouthfuls  have  been  taken,  exces- 
sive and  very  painful  thirst,  are  among  the  common  symp- 
toms of  this  disorder.  A  peculiar  ringing,  barking  cough, 
particularly  in  women,  and  also  night  sweats,  are  not  uncom- 
mon. In  both  men  and  women  I  have  seen  very  obstinate 
retention  of  urine,  caused  by  impaction.  All  these  symptoms 
may  continue  more  or  less  urgent  for  months,  and  aperients 
and  injections  may  be  given,  without  affording  more  than 
temporary  relief. 

When  examining  a  patient,  if  you  make  careful  palpation 
over  the  abdomen,  tumors  may  be  felt  in  the  caecum,  the 
transverse  colon,  or  the  sigmoid  flexure;  under  any  circum- 
stances, in  the  majority  of  cases,  if  you  look  at  the  anus, 
youVill  see  that  it  is  nipple-shaped,  and  if  you  feel  around  the 
anus  you  will  find  the  sphincter  muscle  tightly  contracted 
and  almost  as  hard  as  a  piece  of  wood.  It  is  only  with  dif- 
ficulty that  you  can  introduce  your  finger  into  the  bowel,  and 
having  done  so,  you  will  find  a  ball  of  hardened,  clayey 
faeces  filling  up  the  rectal  pouch.  This  ball  I  have  seen 
almost  as  large  as  a  foetal  head,  and  quite  movable,  so  as  to 
admit  of  liquid  or  thin  motion  passing  round  by  the  sides  of 
it,  thus  giving  rise  to  the  impression  that  diarrhoea  rather 
than  constipation  existed.  So  deceptive  is  the  feeling  this 
mass  gives  to  the  finger,  that  I  have  more  than  once  thought 


IMPACTIOiSr    OF    F^CES.  1 63 

I  must  be  touching  a  tumor;  and  I  have  been  called  in  con- 
sultation several  times,  by  medical  men,  who  had  discovered 
the  impaction,  but  could  not  believe  that  what  they  felt  was 
only  a  collection  of  faeces. 

In  bad  cases  you  must  commence  the  treatment  of  this 
malady  by  thoroughly  breaking  up  the  ball  of  faeces. 

The  best  mode  of  accomplishing  this  is  first  to  put  the 
patient  under  an  anaesthethic,  and  then  forcibly  but  slowly 
dilate  the  sphincters  by  introducing  both  your  forefingers, 
well  oiled,  and  separating  them  in  the  antero-posterior 
direction,  then  again  toward  the  tuberosities  of  the  ischiia. 
You  need  not  tear  the  mucous  membrane,  but  you  so  stretch 
the  muscles  as  to  paralyze  them  for  a  time;  this  done,  you 
can  get  at  the  interior  of  the  rectum  without  any  difficulty,  and 
break  up  the  mass  with  your  finger  or  a  lithotomy  scoop,  or 
the  handle  of  an  old-fashioned  silver  spoon.  The  spasm  of 
the  sphincters  being  thus  overcome,  you  can  do  a  great  deal 
at  one  sitting,  in  fact,  quite  empty  the  rectum. 

After  you  have  thoroughly  broken  up  the  impacted  mass 
you  may  administer  injections  of  soap  and  water  and  oil, 
and  in  this  way  you  will  often  get  rid  of  enormous  quanti- 
ties of  faeces.  When  the  ball  occupying  the  rectal  pouch 
is  cleared  away,  other  masses  generally  come  down,  and  I 
have  seen  as  much  as  would  fill  two  or  three  chamber  utensils 
passed  at  one  operation. 

I  have  found,  in  several  instances,  the  rectum  so  much 
dilated  that  the  upper  part  of  the  bowel  opened  into  the 
pouch  like  a  pipe  into  a  bladder. 

It  is  often  a  considerable  time  before  the  rectum  recovers 
its  power  after  its  great  distention,  and,  therefore,  you  must 
take  care  that  no  reaccumulation  takes  place.  Injections  of 
cold  water,  kneading  the  abdomen,  and  the  exhibition  of  the 
compound  decoction  of  aloes  with  nux  vomica,  will  be  found 
useful.  As  soon  as  the  bowel  is  thoroughly  cleared  out  I  am 
in  the  habit  of  prescribing  the  following  pill,  which  is  very 
effective  in  restoring  power  to  the  colon  and  rectum,  thus 
inducing  a  regular  action  of  the  bowels  : 

]^ .     Ferri  Sulph.  Exsice gr.  J- 

Quiniae  Sulph gr.  j 

Extracti  Nucis  Vomicae gr.  i 

Ext.  Aloes  aq gr.  j 

Extr.  Taraxaci  q.  s.  ut  fiat  pil.  M. 

Take  one  three  times  in  the  day,  after  meals. 


164  IMPACTION    OF    FiECES. 

Faradization  is  most  advantageous  in  these  cases. 

Persons  of  sedentary  habits  are  especially  liable  to  these 
attacks,  exercise  in  the  open  air  must,  therefore  be  taken 
daily. 

'  The  diet  should  not  be  too  liberal.  An  elderly  lady  was 
a  patient  of  mine  on  three  occasions,  with  impaction  and 
loaded  caecum,  and  I  am  sure  it  was  because  she  was  a  very 
hearty  eater  and  never  took  any  exercise.  I  could  neither 
persuade  her  to  walk  more  or  to  eat  less. 

Inpactions  have,  as  I  have  mentioned,  been  often  mistaken 
for  malignant  abdominal  tumors,  but  the  diagnosis  is  usually 
not  difficult  if  observations  be  carefully  made.  There  are  two 
points  of  distinction  which  may  always  be  noticed:  ist.  An 
examination  from  time  to  time  will  show  that  the  tumor 
differs  in  size  and  shape;  this  the  patient  will  often  be  the 
first  to  remark.  2d.  A  very  careful  manipulation  will  detect 
that  the  tumor  is  irregularly  soft  and  has  a  decidedly  doughy 
feeling.  When  the  tumor  is  in  the  sigmoid  flexure  or  rec- 
tum the  introduction  of  the  finger  will  at  once  clear  up  the 
doubt,  if  there  be  any. 

Concretions  in  the  bowels  are  rarer  than  impactions, 
and  they  differ  from  these  in  that  they  are  often  formed 
round  some  foreign  body  and  are  usually  cylindrical  in 
shape.  Concretions  consist  of  animal  and  vegetable  fibres 
matted  together  round  a  nucleus,  which  may  vary  according 
to  circumstances.  In  one  case  a  quantity  of  human  hair 
formed  the  core;  the  patient  had  been  in  a  lunatic  asylum, 
and  in  a  fit  of  mania  had  swallowed  the  hair.  She  had 
suffered  from  attacks  of  intestinal  obstruction  for  months, 
and  she  always  said  there  was  something  in  the  bowel  which 
would  not  pass  through  the  anus.  She  was  brought  to  me 
at  St.  Mark's  Hospital.  I  forcibly  dilated  her  sphincter  and 
with  a  lithotomy  scoop  and  my  finger  succeeded,  after  some 
trouble,  in  removing  a  conical-shaped  mass,  more  than  six 
inches  in  length  by  two  and  a  quarter  inches  in  diameter;  it 
was  covered  with  pus  and  extremely  fetid.  On  cutting 
through  it,  as  I  have  mentioned,  the  centre  was  found  to 
consist  of  human  hair. 

Another  patient  of  mine,  an  elderly  gentleman,  had  an 
obstruction  of  the  rectum  which  I  thought  was  an  ordinary 
impaction,  but  it  was  not  globular  in  form,  and  when  I  tried 
to  break  it  up  I  could  not  do  so,  as  it  slipped  away  and  was 
too  tenacious.  After  dilating  the  sphincters  I  was  able  to 
get  hold  of  it  with  a  pair  of  lithotomy  forceps  and  gradually 


IMPACTION    OF    F^CES.  165 

draw  it  out.  The  nucleus  was  a  large  biliary  calculus,  and 
aVound  it  were  vegetable  and  animal  fibres  and  dried  faeces; 
the  whole  was  covered  by  a  thick  coating  of  mucus  and 
pus.  Eighteen  months  before  he  had  suffered  from  an 
attack  of  gall  stones,  and  no  doubt  this  calculus  had  been 
lodged  in  the  bowel,  probably  in  one  of  the  sacculi  of 
the  colon. 

I  have  already  related  another  case  of  this  kind. 

One  more  case  I  will  record,  as  it  is  peculiar;  here  a  sov- 
ereign formed  the  nucleus.  The  patient,  a  woman,  came  to 
St.  Mark's  Hospital  suffering  from  stricture  of  the  rectum; 
when  I  dilated  the  stricture  I  found  a  large  mass  above  it. 
Purgatives  and  enemata  not  effecting  its  removal,  I  eventu- 
ally brought  it  down  with  a  scoop  and  my  finger;  it  was 
cylindrical  in  form.  On  tearing  it  up  to  examine  its  struc- 
ture I  found  in  its  centre  the  coin  I  have  mentioned.  Quite 
fifteen  months  before  the  woman  had  swallowed  a  sovereign, 
and  she  had  sought  for  it  in  her  motions,  but  failed  to  find  it; 
she  had  not  any  idea  that  it  had  not  passed.  I  think  it  very 
likely  that  at  that  time  she  had  incipient  stricture  of  the  rec- 
tum, and  consequently  the  piece  of  money  did  not  escape 
from  the  bowel. 

I  will  not  occupy  more  space  on  this  subject;  the  cases 
are  somewhat  rare  and  the  treatment  simple  enough.  When 
the  mass  comes  down  near  the  anus  it  must  be  removed 
bodily;  you  will  find  itso  tenacious  that  you  can  not  break  it 
pu  like  an  ordinary  impaction.  Unless  you  dilate  the  sphincter 
you  will  have  very  great  difficulty  in  extracting  these  con- 
cretions; in  fact,  it  will  be  almost  impossible  to  do  so. 

It  is  very  curious  how,  sometimes,  small  substances  fail 
to  traverse  the  alimentary  canal  safely,  and  how,  at  other 
times,  very  large  bodies  pass  without  producing  any  severe 
or  dangerous  symptoms.  There  are  cases  related  by  Sir 
James  Paget,  Mr.  Henry  Smith,  and  others,  where  a  con- 
siderable portion  of  a  set  of  false  teeth,  mounted  in  gold, 
was  swallowed  and  not  arrested  anywhere  in  the  intestines. 

There  is  one  thing  we  should  recollect  when  such  a  case 
comes  before  us,  that  is,  never  give  a  purge.  You  may  tell 
your  patient  to  eat  very  freely  of  solid  material,  such  as  suit- 
pudding,  bread,  and  the  like,  so  as  to  form  full-sized  cohesive 
motions. 

These  cases  must  not  teach  us  to  lightly  estimate  the 
danger  of  swallowing  foreign  bodies  ;  many  cases  are  on 
record  where  such  a  simple  matter  as  a  cherry  stone  has 


l66        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

caused  death,  by  setting  up  ulceration  and  perforation  of  the 
bowel,  usually  the  caecum  or  vermiform  appendix. 

I  saw,  some  time  back,  a  case,  with  Dr.  Nash  and  Mr. 
Clover,  of  a  fine  young  lad  who  lost  his  life  from  peritonitis 
caused  by  perforation  of  the  appendix  vermiformis.  The 
foreign  body  appeared  to  be  a  small  portion  of  wood,  around 
which  fecal  matter  had  deposited,  augmenting  its  size  to 
about  that  of  a  small  date  stone,  but  pointed  at  each  end. 

The  symptoms  were  at  first  not  very  pronounced,  but  the 
fever  was  soon  great  and  accompanied  by  much  delirium. 
No  operative  interference  was  resorted  to,  the  diagnosis 
being  that  the  obstruction  to  action  of  the  bowels  was  caused 
by  peritonitis,  the  result  of  probable  perforation  of  the  caecum 
or  its  appendix.     The  post  mortem  verified  the  diagnosis. 


CHAPTER  XVII 

ULCERATION    AND    STRICTURE    OF    THE    RECTUM. 

Ulceration  extending  above  the  internal  sphincter,  and 
frequently  situated  entirely  above  that  muscle,  is  not  a  very 
uncommon  disease  ;  it  inflicts  great  misery  upon  the  patient, 
and  if  neglected,  leads  to  conditions  quite  incurable,  and  the 
patient  dies  of  exhaustion,  unless  extraordinary  m*eans  are 
resorted  to.  In  the  earlier  stages  of  the  malady,  careful, 
rational,  and  prolonged  treatment  is  often  successful,  and 
the  patient  is  restored  to  health  ;  I  wish  I  could  say  the 
same  of  the  severe  and  long-standing  cases.  Ulceration  of 
the  rectum  can  be  mistaken  only  for  maUgnant  disease  ;  but 
when  the  symptoms  are  carefully  considered,  and  the  finger 
is  well  educated,  there  can  but  very  occasionally  be  any  error 
in  diagnosis  committed.  As  the  earlier  manifestations  are 
fairly  amenable  to  treatment,  it  is  of  the  utmost  importance 
that  the  diaease  should  be  recognized  early.  Unfortunately, 
it  rarely  is  so  ;  the  symptoms  are  obscure  and  insidious,  the 
suffering  at  first  but  slight,  and  thus  the  patient  deceives,  not 
only  himself,  but  his  medical  attendants,  by  the  little  heed  he 
gives  to  the  complaint. 

In  the  majority  of  these  cases  the  earliest  symptom  is 
morning  diarrhoea,  and  that  of  a  peculiar  character  ;  in  my 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  167 


Opinion  it  is  quite  indicative  of  the  disease,  and  can  be  con- 
founded only  with  similar  symptoms  due  to  cancer.  The 
patient  will  tell  you  that  the  instant  he  gets  out  of  bed  he 
feels  a  most  urgent  desire  to  go  to  stool  ;  he  does  so,  but  the 
result  is  not  satisfactory.  What  he  passes  is  generally  wind, 
a  little  loose  motion,  and  some  discharge  resembling  "  coffee 
grounds  "  both  in  color  and  consistency  ;  occasionally  the 
discharge  is  like  the  "  white  of  an  unboiled  egg  ;  "  or  "  a 
jelly-fish  ;  "  more  rarely  there  is  matter.  The  patient  in  all 
probability  has  tenesmus,  and  does  not  feel  relieved  ;  there 
is  a  somewhat  burning  and  uncomfortable  sensation,  but  not 
actual  pain  ;  before  he  is  dressed,  very  likely,  he  has  again 
to  seek  the  closet  ;  this  time  he  passes  more  motion,  often 
lumpy,  and  occasionally  smeared  with  blood.  It  may  also 
happen  that  after  breakfast,  hot  tea  or  coffee  having  been 
taken,  the  bowels  will  again  act ;  after  this  he  feels  all  right, 
and  goes  about  his  business  for  the  rest  of  the  day,  only, 
perhaps,  being  occasionally  reminded,  by  a  disagreeable  sen- 
sation, that  he  has  something  wrong  with  his  bowel.  Not 
by  any  means  always,  but  at  times,  the  morning  diarrhoea  is 
attended  with  griping  pain  across  the  lower  part  of  the 
abdomen  and  great  flatulent  distention.  When  a  medical 
man  is  consulted  the  case  is,  in  all  probability,  and  quite 
excusably,  considered  one  of  diarrhoea  of  a  dysenteric 
character,  and  treated  with  some  stomachic  and  opiate 
mixture,  which  affords  temporary  relief.  After  this  condi- 
tion has  lasted  for  some  months,  the  length  of  this  period  of 
comparative  quiescence  being  influenced  by  the  seat  of  the 
ulceration  and  the  rapidity  of  its  extension,  the  patient 
begins  to  have  more  burning  pain  after  an  evacuation,  there 
is  also  greater  straining  and  an  increase  in  the  quantity  of 
discharge  from  the  bowel ;  there  is  now  not  so  much  jelly- 
like matter,  but  more  pus — more  of  the  coffee-ground 
discharge,  and  blood.  The  pain  suffered  is  not  very  acute, 
but  very  wearing  ;  described  as  like  a  dull  toothache,  and  it 
is  induced  now  by  much  standing  about  or  walking.  At  this 
stage  of  complaint  the  diarrhaea  comes  on  in  the  evening  as 
well  as  the  morning,  and  the  patient's  health  begins  to  give 
way,  only  triflingly  so,  perhaps,  but  he  is  dyspeptic,  loses  his 
appetite,  and  has  pain  in  the  rectum  during  the  night,  which 
disturbs  his  rest  ;  he  also  has  wandering  and  apparently 
anomalous  pains  in  the  back,  hips,  down  the  leg,  and  some- 
times in  the  penis.  There  is  yet  another  symptom  present 
in  the  later  stages,  marking  the  existence  of  some  slight  con- 


l68        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

traction  of  the  bowel,  viz.,  alternating  attacks  of  diarrhoea 
and  constipation,  and  during  the  attacks  of  diarrhoea  the 
patient  passes  a  very  large  quantity  of  faeces.  These  seizures 
are  attended  with  severe  colicky  pains  in  the  abdomen,  faint- 
ness,  and  not  unfrequently  sickness. 

As  the  ulceration  extends,  attempts  at  healing  take  place: 
these  result  in  infiltration  and  thickening  of  the  submu- 
cuous  and  muscular  tissues,  and  consequent  diminution  of 
the  calibre  of  the  bowel,  so  that  real  stricture  of  various 
forms  supervenes.  Coincident  with  all  this  there  results  a 
gradual  loss  of  the  contractile  power  of  the  rectum,  and 
almost  complete  immobility,  so  that  the  lower  part  of  the 
gut  is  converted  into  a  passive  tube  through  which  the  faeces, 
if  fluid,  trickle;  but  if  solid,  they  stick  fast  until  pushed 
through  by  fresh  formations  above  them.  Invariably,  also, 
there  is  loss  of  power  in  the  sphincters.  When  diarrhoea  is 
present  the  patient  has  little  or  no  control  over  his  motions. 
Usually  by  this  time  abscesses  have  formed,  or  are  in  pro- 
cess of  formation,  and  these  breaking,  soon  become  fistulae. 
I  have  seen  persons  with  as  many  as  eight  external  orifices, 
some  situated  three  inches  or  more  from  the  anus. 

On  examining  these  cases  of  ulceration  of  the  rectum, 
various  conditions  may  be  noticed,  according  to  the  stage 
to  which  the  disease  has  advanced.  In  the  earlier  period 
you  may  often  feel  an  ulcer  situated  dorsally  about  one  and 
a  half  inches  from  the  anus,  oval  in  form,  perhaps  an  inch 
long  by  half  an  inch  wide,  surrounded  by  a  raised  and 
sometimes  hard  edge;  there  is  acute  pain  caused  on  touch- 
ing it,  and  it  may  be  readily  made  to  bleed.  With  a  specu- 
lum you  can  distinctly  see  the  ulcer,  the  edges  well  marked, 
the  base  grayish  or  very  red  and  inflamed  looking,  the  sur- 
rounding mucuous  membrane  being  probably  healthy;  in  the 
neighborhood  of  the  ulcer  may  often  be  felt  some  lumps, 
which  are  either  gummata  or  enlarged  rectal  glands.  This 
is  the  stage  in  which  the  disease  is  often  curable,  as  I  shall 
show  when  speaking  of  treatment.  Later  in  the  progress  of 
the  malady,  you  will  observe  deep  ulcers,  with  great  thick- 
ening of  the  mucous  membrane,  often,  also,  roughening  to 
a  considerable  extent,  as  though  the  mucous  membrane  had 
been  stripped  off.  At  this  stage  you  generally  notice,  out- 
side the  anus,  swollen  and  tender  flaps  of  skin,  shiny,  and 
covered  with  an  ichorous  discharge;  these  flaps  are  com- 
,monly  club-shaped,  and  are  met  with  also  in  malignant  dis- 
ease; but  in  the  early  development  of  the  disease  no  ulcer- 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  169 

ation  is  found  near  the  anus  nor  at  the  aperture.  It 
is  in  private  practice  that  we  have  the  best  opportunity 
of  seeing  these  cases  early,  and  I  most  positively  repeat  that 
the  large  majority  do  not  commence  by  any  manifestation 
at  the  anus,  such  as  growths  or  sores;  occasionally  a  fissure 
may  be  the  first  lesion,  and  the  ulceration  extend  from  the 
wound  made  in  attempting  to  cure  it;  this  is,  however,  the 
exception  to  the  rule,  and  I  will  further  on  relate  some 
cases  to  show  that  what  I  have  stated  is  correct.  So  defi- 
nite is  this  external  appearance  in  long-standing  disease, 
that  one  glance  is  sufficient  to  enable  an  expert  to  predicate 
the  existence  of  either  cancer  or  severe  ulceration;  these 
external  enlargements  are  the  result  of  the  ulceration  going 
on  in  the  bowel,  and  the  irritation  caused  by  almost  constant 
discharge.  The  ulceration  may  be  confined  to  a  part  of  the 
circumference  of  the  bowel,  or  it  may  extend  all  round,  and 
for  some  distance,  but  not  usually  for  more  than  four  inches 
up  the  rectum.  It  also  probably  will  have  traveled  down- 
ward close  to  the  anus,  and  then  the  pain  is  sure  to  be  very 
severe,  because  the  part  is  more  sensitive  and  more  exposed 
to  external  influences  and  practices. 

AVhen  the  disease  has  reached  this  stage,  of  course,  stric- 
ture and  most  probably  fistulse  will  be  present,  as  I  have 
already  mentioned;  and  possibly,  but  not  frequently,  perfo- 
ration into  the  bladder,  into  the  vagina,  or  the  peritoneal 
cavity,  may  occur.  The  state  of  the  patient  is  now  lament- 
able; his  or  her  aspect  resembles  that  of  a  sufferer  from 
malignant  disease,  and  no  remedy  short  of  lumbar  colotomy 
offers  much  chance  of  even  prolonging  life.  You  may 
relieve  these  patients,  but  can  rarely  do  more;  a  cure  can 
scarcely  be  expected.  I  have  seen  ulceration  utterly  destroy 
both  the  anal  sphincters,  so  that  the  anus  was  but  a  deep, 
ragged  hole.  Here  is  such  a  case,  which  was  under  my  care 
at  St.  Mark's  Hospital. 

Matilda  G ,   admitted  under  my  care  January,  187 1. 

She  is  a  married  woman,  twenty-eight  years  of  age.  Five 
years  ago  she  was  a  patient  of  mine  with  stricture  and  ulcer- 
ation. She  went  on  tolerably  well,  and  continued  so  up  to 
about  eighteen  months  back;  since  then  she  has  suffered 
much;  she  had  constant  pain  and  discharge  from  the  bowels; 
she  either  has  constipation  or  diarrhoea.  There  is  entire 
incontinence  of  faeces.  The  straining  and  bearing  down  are 
very  distressing;  her  aspect  is  worn  and  sallow;  she  is  not 
very  emaciated;  there  is  no  evidence  of  syphilis  or  consump- 


170        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

tion.  On  examination  a  large,  ragged,  deep  hole  is  seen 
instead  of  an  anus;  it  is  surrounded  by  swollen  flaps  of 
skin,  two  of  which  are  perforated  by  fistulae;  the  hole  meas- 
ures about  two  inches  each  way,  and  there  is  not  a  vestige  of 
sphincter  muscle  left.  On  introducing  the  finger  into  the 
bowel,  it  is  found  quite  blocked  up  by  contraction  and 
thickening;  only  a  very  small  aperture  can  be  felt,  but  into 
this  the  end  of  the  finger  cannot  be  passed.  Chloroform 
being  given,  she  strained  down  so  violently  that  the  strictured 
portion  of  the  bowel  was  forced  outside,  so  that  the  ulcera- 
tion and  stricture  could  be  plainly  seen.  The  aperture  was 
not  larger  than  a  No.  lo  male  catheter.  I  saw  this  patient 
over  and  over  again  ;  she  was  always  benefited  by  treat- 
ment, but  not  cured;  at  length  she  died  in  the  workhouse. 

Years  may  have  elapsed  before  the  dreadful  condition  I 
have  been  describing  has  been  brought  about,  but  it  is  one 
we  only  too  frequently  see  at  St.  Mark's. 

Patients  suffering  from  ulceration  and  stricture  are  very 
liable  to  attacks  of  a  low  form  of  peritonitis,  attended  with 
considerable  abdominal  pain,  often  intense  for  a  short 
period.  There  are  generally  one  or  more  spots  that 
are  tender  on  pressure;  there  is  tympanites,  often  vomiting, 
especially  on  first  assuming  the  erect  position  in  the  morn- 
ing, and  generally  the  pain  is  brought  on  by  standing  or 
moving  about;  these  attacks  are  sure  to  end  in  diarrhoea. 
The  treatment  should  be  perfect  rest  in  bed,  spoon  diet,  and 
opium  "may  be  given  freely;  fomentations  relieve  the  pain, 
but  I  have  not  seen  any  benefit  result  from  counter-irrita- 
tion. I  have  often  found  that  calomel  and  opium  given  for 
some  time  is  advantageous  in  these  cases. 

When  making  a  post-mortem  examination  in  such  cases  I 
have  observed  effusion  into  the  peritoneal  cavity,  and  often 
considerable  old  and  recent  adhesions  between  the  intes- 
tines; the  peritoneum  is  also  thickened.  In  bad  ulceration 
you  see  what  great  destruction  of  tissue  has  taken  place.  I 
found  the  whole  of  the  rectum  and  sigmoid  flexure  involved 
in  ulceration,  and  great  thickening  and  contraction  of  the 
calibre  of  the  bowel,  caused  by  the  attempt  at  repair  in 
various  parts.*  The  connective  tissue  here  and  there  is  so 
removed  as  to  leave  large  bridges  of  indurated  muscle  and 
roughened  mucous  membrane;  and  there  is  ulceration,  so 
deep  in  places  that  perforation  must  have  occurred  but  for 
the  adhesion  kindly  made  by  nature  to  the  adjacent  parts. 
In  other  situations  the  muscular  coat  is  laid  quite  bare,  and 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 


171 


I  have  seen  more   than   one  case  in  which  necrosis  of  the 
sacrum  has  taken  place. 

The  following  table  of  seventy  cases  which  have  been 
under  my  care  at  St.  Mark's  Hospital  exhibits,  I  think, 
many  points  worthy  of  consideration: — 


Seventy  Cases  of  Ulceration  and  Stricture  of  the  Rectum,  taken 
from  Mr.  Allingha77i' s  Practice  at  St.  Mark's  IIosj)ifal. 


I  Constitutional 
syjihilis  or  not. 


Yes,  tertiary 
Yes,  nodes 


Severe  cons. 

syph. 
No  iiistory  or 

apearance 
No  syphilis  ; 

struma 


Cons.  syph.  , 
nodes  on  fore- 
head 

No  history  of 
syph. 

Cons.  syph.  ;   (8 

years) 
No  symptoms 

of  syphilis  nor 

history 
Syphilis  well 

marked 

Ditto 

Probably, 
Sore  throat 
now 

No  symptoms  or 

hist,  of  syph. 
Cons.  syph. 

No  symptoms 
or  history 

No  symptoms  or 
.  history 
Cons.  syph. 


None 


Stricture  a?td  ulceration, 
luhere  _found. 


Stricture  2  inches  up ; 
ulceration  above  and  be- 
low 

Ulceration  from  anus  ; 
stricture  2  inches 

Stricture  impermeable  high 

^  up 

Severe  ulceration  and  stric- 
ture 2  inches  from  anus 

Small  ulcer  ;  stricture  t% 
inch  ;  ulceration  above 
stricture 

Stricture  1%  inch  ;  hyper- 
trophy of  nymphae 

Stricture  2  inches  ;  ulcera- 
tion high  up 

Stricture  3  inches  long,  % 

inch  from  anus 
Extensive  ulceration  ;  two 

strictures  high  up 

Stricture  1%  inch  from 
anus  ;  ulceration  above 
and  below  ;  hardness 

Stricture  2  inches  from 
anus  ;  severe  ulceration 

Stricture  just  within  reach 
of  finger;  no  ulceration 
between  anus  and  stric- 
ture 

Stricture  two  inches  ;  much 
ulceration 

Stricture  x^/i  inch  from 
anus  ;  ulceration  above 

Stricture  2%  inches  ;  bad 
ulceration  above  and  be- 
low stricture 

Stricture  j%  inch  ;  ulcera- 
tion near  anus 

Stricture  r%  inch  ulcera- 
tion deep  above  and 
below  stricture 

Simple  Stricture  2  inches 
from  anus  ;  much  indura- 
tion but  no  ulceration 


Complications  and 
observations. 


Fistula;  mucous  tubercles; 
primary  infection  5  years 
since. 

Sores  on  labia  ;  fistula ; 
primary  symptoms  5 
years  ago. 

Recto-vaginal  fistula;  colo- 
tomy  ;  lived  18  months. 

No  complication  ;  outside 
parts  normal. 

Outward  parts  quite  npr- 
mal ;  hymen  present ; 
under  treatment  8  years; 
died,  exhaustion. 

Ulceration  very  high;  colo- 
tomy  3  years  ago ;  now 
living. 

Fistulae  in  all  directions, 
from  which  great  indura- 
tion ;  colotomy  ;  success. 

No  complications  ;  colo- 
tomy successful. 

Attempted  colotomy  (right 
side)  ;  death  56  hours. 

Large  flaps  of  skin  outside, 
and  fistula. 

Recto-vaginal  fistula ;  sy- 
philis 7  years  at  least. 

Recto-vaginal  fistula;  anus 
not  affected. 


Fistula;  no  disease  of  anus; 
came  on  as  abscess. 

Anus  normal;  syphilis  12 
years  ;  had  treatment. 

Fistula  both  sides  of  anus; 
large  flaps  of  hypertro- 
phic skin;  discharging. 

Large  fibroid  polypus;  easy 
cure. 

Dorsal  fistula;  anus  normal; 
syhilis  18  mos.,  rash 
scaly,  and  ulceration  on 
tongue. 

No  internal  abnormality  ; 
division  and  lasting  cure. 


172         ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 


No. 

>f^^ 

>9 

40 

20 

20 

21 

30 

22 

42 

P3 

28 

S4 

39 

25 

24 

26 

53 

27 

27 

.8^ 

25 

29 

33 

30 

22 

31 

28 

32 

31 

33 

50 

34 

37 

35 

22 

S6 

13 

37 

28 

38 

25 

39 

33 

40 

37 

41 

27 

42 

37 

Constitutional 
syphilis  or  not . 


F.    Cons.  syph. 
F.   Ditto 

!  , 

F.   No  history  of 
I     syphilis 

F.    Syphilis  well 
I     marked 

F.  ^None 
F.  I  Cons,  syphilis 
None 


F. 


Cons,  syphilis 
None 

Cons,  syphilis 

None 
None 

Cons,  syphilis 


F.    None 

I 
F.  ;None 

F.    Cons,  syphilis 

F.  [None 

i 

F.  jNone 

F.    Cons,  syphilis 


Ditto 

Doubtful  ;    no 

historj'  or 

symptoms 

Cons,  syphilis 

None 

Cons,  syphilis 


Stricture  and  ulceration^ 
•where  J'oufid. 


Ulceration  commencing  i 
inch  above  anus,  stricture 
2  inches 

Tight  stricture  2  inches  ; 
ulceration 

Very  little  stricture  2  in- 
ches ;  superficial  ulcera- 
tion 

Stricture  i  inch  up  ;  ulcera- 
tion severe  and  deep 

Annular  cord-like  stricture 
2  inches  ;  ulceration  near 
anus 

Stricture  1%  inch  from 
anus  ;  not  much  ulcera- 
tion 

Stricture  2  inches,  dense 
and  long  ;  ulceration  se- 
vere j 

Stricture  tight  ;  no  ulcera- 
tion above  or  below  j 

Stricture  just  inside  anus  ; 
no  ulceration  ;  cure  b^' 
incision  and  dilation 

Stricture  2  inches  from 
anus;  ulceration  below 
and  above. 

Stricture  2  inches  from 
anus  ;  ulceration  severe    | 

Stricture  annular,  i^^  in- 
ches up  ;  ulceration  se-i 
vere 

Stricture  severe  and  long,' 
commencing  i  inch  fromj 
anus  ;  deep  and  extensive  I 
ulceration  I 

Stricture  i]A,  inch ;  much 
soft  ulceration  I 

Stricture  2  inches  up; 
ulceration  above  and  be-j 
low  I 

Stricture^  inch  from  anus; 
ulceration  high  up  j 

Stricture  2%  inches  up ; 
ulceration  above  and! 
below  I 

Stricture  about  2  inches  up; 
little  ulceration 

Stricture  2  inches  up  ; 
ulceration  above  and  be- 
low I 

Stricture  ij4  inches  up ; 
ulceration  above  and  be- 
low 

Stricture  just  within  reach; 
ulceration  below 


Complications  and 

observations. 


Anus  naturaL 


Mucous  tubercles ;  hyper- 
trophied  nymphse. 

Verrucse  ;  no  sores  ;  speedy 
cure. 

Fistula  ;  great  induration 
and  swollen  lumps 
around  anus. 

No  complication 


Large  superficial  sore  in 
perineum,  extending  into 
anus  ;  fistula. 

Recto-vaginal  fistula,  com- 
menced after  child-birth; 
colotomy,  success. 

Fistula  in  ano ;  syphilis  5 
years. 

No  complication. 


Syphilitic  rash  and  sores  ;  9 
years  of  sj'philis. 

Fistula  in  ano  ;  been  oper- 
ated upon  several  times. 

Procidentia  recti ;  a  curious 
case,  it  comes  through 
the  contraction. 

Several  large  external 
growths  and  three  fistu- 
lous sinuses. 

Outward    parts      normal  ; 
died;  gradual  exhaustion. 
No  complication. 


Rupia  ;  fistula  in   ano  ;  10 

years  syphilis. 
Haemorrhoids. 


Fissure  and  polypus. 

No  complication  ;  10  years 
syphilis. 

Fistula  through  labia  and 
into  anus  ;  growths. 

Fistula  in  ano  ;  recto-vagi- 
nal fistula. 


I  Stricture  2  inches;   severe  Fistula  ;     growths;    colo- 

I     ulceration  tomy  ;  success. 

j  Stricture  annular,  3  inches  None  ;    cured    by  incisioa 

up  ;  severe  ulceration  and  dilatation. 

Stricture  i}^  inch  up  ;  veryjHuge  outside  growths  and 

severe  ulceration  labial  fistula ;  colotomy ; 

I    euccess. 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 


173 


Vo. 

^^^ 

43 

27 

44 

30 

45 

26 

46 

25 

47 

35 

48 

22 

49 

30 

50 

30 

51 

25 

52 

24 

53 

28 

54 

18 

55 

25 

56 

32 

57 

22 

58 

29 

59 

63 

60 

47 

6i 

50 

62 

53 

63 

40 

64 

34 

65 

26 

66 

38 

67 

29 

68 

19 

Sex 


F. 
F. 
F. 

F. 

M. 

M. 
M. 

M. 
M. 

M. 
M. 
M. 


Constitutional 
syphilis  or  not. 


None 

Cons,  syphilis 

None 

Cons,  syphilis 

None 

Cons,  syphilis 
Very  doubtful 
Cons,  syphilis 

None 

Cons,  syphilis 

Ditto 

Ditto 
Ditto 

Ditto 

None 
None 
None 

None 

Cons,  syphilis 

Ditto 

None 

Cons,  syphilis 
Ditto 

Ditto 
None 
Cons,  syphilis 


Stricture  and  ulceration 
where  /ound. 


Stricture  i  inch  up  ;  super- 
ficial ulceration 

Stricture    2     inches      up 
ulceration  slight 

Stricture  1%  inch  up  ;  se- 
vere, deep  ulceration 

Stricture  2  inches  up  ; 
ulceration  above  and  be- 
low 

Ulceration,  so  that  the  os 
and  cervix  uteri  came 
through  into  the  rectum 

Impermeable  stricture  2 
inches  up 

Stricture  2  inches  up  ;  not 
much  ulceration 

Stricture  high  up  ;  ulcera- 
tion severe 

Stricture  2  inches  ;  ulcera- 
tion slight 

Stricture  i  inch  up;  ulcera- 
tion severe 

Stricture  2  inches  up ; 
ulceration  only  above  ihe 
stricture 

Stricture     \%     inch  ;      no 

ulceration  at  all 
Stricture   2j^    inches    up  ; 

ulceration    severe  above 

and  below 
Stricture   very   high,   only 

just  to  be  felt;  ulceration 

very  deep 
Stricture  1%  inch  up  ;  very 

little  ulceration 
Stricture     3     inches      up  ; 

ulceration  below  slight 
Stricture  i  inch  up  ;  ulcera- 
tion above 

Stricture  only  just  to  be 
felt ;  ulceration  below 

Stricture  3  inches  from 
anus  ;  much  ulceration 

Stricture  2  inches  above 
anus  ;  ulceration  from 
anus 

Stricture  3  inches  ;  ulcera 
tion  all  around  rectum 


Stricture  i  inch  ;  ulceration 

above  and  below 
Stricture  i^  inch  ;  ulcera 

tion  severe  above 

Stricture  2  inches  ;  ulcera- 
tion severe 

Stricture  i  inch,   annular ; 
slight  ulceration 

No  stricture  :  all  sloughed 
away 


Complications  and 
observations. 


None ;    cured   by  division 

and  dilatation. 
Recto-vaginal  fistula. 

Club-shaped  growths   out- 
side around  anus 
Fistula  in  ano. 


The  uterus  could  not  be 
returned  ;  she  menstruat- 
ed into  rectum. 

Constipation  3  weeks  ;  co- 
lotomy ;  success. 

None. 

Fistula  and  outside 
growths  ;  syphilis  5  or  6 
years. 

Internal  Fistula;  burrowinsj 
up  under  stricture. 

Fistula  ;  growths  ;  rupial 
rash. 

Fistula  ;  very  recent  stric- 
ture, only  noticed  6 
months  ;  indurated  sores 
on  nympha. 

Verrucae  ;  labial  abscess. 

Haemorrhoids  and  fistula. 


Fistula  ;  several  sinuses ; 
colotomy ;  success. 

Disease  of  uterus. 

Fistula  in  ano  and  fissure. 

Four  fistulse  around  anus, 
one  perforating  the  vagi- 
nal wall. 

Fistula  in  ano  ;  complete 
opening  below  stricture. 

Numerous  fistulse ;  great 
debility  ;  went  home  and 
died. 

Several  hard  ulcerated 
growths ;  very  badly 
syphilized,  5  years. 

Bad  fistula,  fecal  matter 
passing  through;  colo- 
tomy (alive  8  years  after 
operation) . 

Ulceration  down  to  anus  ; 
fistula  in  ano. 

Stricture  almost  impass- 
able ;  colotomy  (alive 
now,  ID  years). 

Two  fistulous  sinuses  ;  bad 
condition. 

Phthisical ;  anus  lost  all 
power. 

Phthisis  combined  with 
syphilis  h ad  played  havoc 
with  him. 


174        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 


No. 

Age 

Sex 

1 
Constitutional  \stricture  and  ulceration^ 
syphilii  or  not..            where  found. 

1 

Complications  and 
observations. 

69 
70 

80 
50 

M. 

M. 

None 
None 

Stricture    extending    from 
anus  3   inches   up,   very 
hard 

Annular  stricture  2  inches 
up  ;    not    severe  ulcera- 
tion 

Thought  to  be  cancer,  but 
dilatation  and  small 
doses  of  mercury  cured 
him. 

Anus  normal  ;  speedy  cure 
by  division  and  dilata- 
tion. 

We  may  briefly  call  attention  to  some  important  points  in 
the  above  table.  In  70  patients,  60  were  females  and  10 
males,  a  large  predominance  of  the  former,  but  not  so  great 
as  has  been  given  by  some  authors.  Now  you  will  find  on 
examining  the  table  that  35  had  suffered  from  undeniable 
constitutional  syphilis,  while  5  had  some  symptoms,  but  not 
decisive,  of  ever  having  had  the  disease,  so  I  think  this 
number  should  be  deducted  from  the  whole  number  70, 
before  we  consider  the  statistics  of  the  rest,  viz.  65,  and  we 
find  35  were  most  undoubtedly  syphilitic,  and  30  as 
undoubtedly  never  had  contracted  syphilis,  and  many  never 
any  venereal  disease. 

The  males,  though  small  in  number,  are  worthy  of  a 
moment's  consideration  ;  of  the  10  males,  6  had  suffered  from 
some  form  of  syphilis  ;  but  4  had  not,  and  there  was  great 
probability  that  they  had  not  been  affected  by  any  venereal 
disease  ;  they  denied  any  venereal  taint,  and  I  think,  from 
the  way  they  spoke,  and  the  desire  they  had  not  to  deceive 
me  (as  I  made  it  a  matter  of  great  importance  to  them,  as 
regards  treatment,  that  they  should  tell  me  the  truth),  I  felt 
bound  to  believe  them. 

Ten  of  my  cases  were  subjected  to  colotomy  in  the  lumbar 
region,  and  for  the  most  part  did  well,  and  I  believe  several 
(5  or  6)  are  now  alive.  Two  of  the  women  have  married 
since  the  operation.  In  one  female  I  attempted  to  open  the 
ascending  colon,  and  after  a  most  careful  search  I  failed  to 
find  it,  but  in  mistake  opened  the  duodenum,  as  it  embraces 
the  head  of  the  pancreas.  I  like  to  mention  this  case,  to 
show  how,  in  difficult  cases,  a  practiced  colotomist  may  go 
astray.  This  patient  had  a  very  enlarged  liver,  and  was  in 
the  habit  of  tight  lacing,  so  the  liver,  being  pressed  down- 
ward, carried  the  ascending  and  transverse  colon  diagonally  to 
the  left  side,  and  Xht  post-7?iortem  examination  showed  it  was 
next  to  impossible  to  reach  the  ascending  colon  from  my 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.         1 75 

incision.  I  must  observe  that  the  duodenum  when  brought 
up  from  a  depth  is  very  like  the  colon.  Four  hours  after  the 
operation  I  knew  what  I  had  done,  as  a  large  and  constant 
flow  of  bile  took  place  from  the  wound  ;  she  vomitted  fre- 
quently, could  take  no  nourishment,  and  died  on  the  third 
day. 

Before  and  since  that  operation  I  have  opened  the  ascend- 
ing colon  and  found  no  particular  difficulty,  but  there  is  no 
doubt  that  the  ascending  colon  is  more  liable  to  be  dis- 
placed than  the  descending.  I  do  not  in  any  way  wish  to 
extenuate  my  error  in  the  case  ;  at  the  time  I  grieved  seri- 
ously over  it,  and  I  have  never  forgotten  it.  I  always  think 
I  ought  to  have  made  a  more  careful  examination,  and  to 
have  found  that  the  liver  was  enlarged,  and  came  so  low 
down  as  the  crest  of  the  ilium,  and  so  was  almost  certain  to 
push  the  ascending  colon  out  of  place  ;  further,  I  now  think 
I  ought  by  manipulation  and  percussion  to  have  found  that 
the  ascending  and  transverse  colon  was  out  of  position. 
However,  we  may  learn  more  from  our  errors,  if  we  take 
them  to  heart  and  study  them,  than  from  all  our  successful 
cases.  In  forty-seven  operations  the  case  I  have  related  is 
the  only  one  in  which  I  made  any  mistake  or  failed  to  find 
the  colon. 

Of  the  30  patients  who  had  never  been  syphilized,  it  was 
possible  that  many  more,  but  highly  probable  that  13,  had 
never  had  any  venereal  affection  whatever.  Inoculation  in 
all  these  cases  proved  abortive,  either  there  being  no 
result,  or  only  a  small,  evanescent  pimple  appearing. 

The  cases  here  mentioned  are  No.  5,  observed  for  8  years, 
died  of  exhaustion  ;  would  not  submit  to  colotomy. 

No.  7.  Colotomy  performed  with  success,  all  ulcers  heal- 
ing ;  this  patient  has  now  been  seven  years  in  good  health. 

No.  16.  Had  large  fibroid  polypus  with  stricture  and 
ulceration  ;  removal  of  polypus  and  dilatation  with  incision 
effected  a  cure. 

No.  18.  Division  effected  a  permanent  cure. 

No.  25.  Colotomy  effected  cure,  patient  watched  for  years 
and  found  well ;  eventually,  all  the  strictures  being  cured, 
the  wound  in  the  loin  was  closed. 

No.  29.  Division  of  fistula  and  dilatation  of  stricture 
effected  a  cure. 

No.  $6.  Fissure  and  polypus,  with  ulceration  and  strict- 
ure ;  operation,  subsequent  dilatation  ;  cured  ;  some  months 
after  found  well. 


176        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

No.  43.  Stricture  and  ulceration  cured  by  incision  and 
dilation. 

No.  57.  Disease  of  uterus,  enlargement  of  fundus,  retro- 
version, Hodge,  dilatation,  cure. 

No.  59.  Stricture  and  fistula,  ulceration,  careful  division 
of  fistula  and  stricture,  cure  permanent. 

No.  67.  Male,  annular  stricture  and  ulceration,  phthisis, 
relief. 

No.  69.  Stricture  very  long  and  hard,  gradual  dilatation 
of  stricture,  cure,  and  no  relapse. 

No.  70.  Annular  stricture  high  up,  incision  and  dilatation 
of  stricture,  cure. 

With  regard  to  inoculation,  I  performed  it  on  many 
patients  in  whom  severe  constitutional  symptoms  of  syphilis 
with  outside  growths  existed,  and  never  got  a  true  chancroid 
as  the  result ;  I  noticed  many  small  pimples  and  sores, 
which  healed  in  a  few  days,  but  never  a  typical  soft  chancre) 
I  therefore  certainly  did  not  inoculate  from  a  soft  sore. 

I  know  many  of  these  patients  died  after  years  of  treat- 
ment, numbers  of  them  being  admitted  and  readmitted  into 
the  hospital.  They  die  either  of  some  intervening  acute 
disease,  obstruction  in  the  bowel,  or  gradually  undermined 
and  broken-down  health  ;  the  workhouse  infirmary  often 
sees  their  end,  which  may  be  very  rapid.  In  sixteen  cases  I 
performed  Verneuil's  operation  of  linear  rectotomy,  but 
always  with  the  knife,  never  with  the  ecraseur  or  galvanic 
cautery  as  he  has  recommended.  One  thing  I  have  learned 
in  m.y  long  practice — not  to  fear  any  haemorrhage  from  the 
rectum. 

This  is  the  essence  of  Prof.  Verneuil's  operation  :  the 
whole  stricture  must  be  divided  from  its  upper  edge  down  to 
the  coccyx,  and  through  its  entire  depth.  Thus  a  deep 
drain  is  made,  from  which  all  discharges  freely  flow,  and  as 
it  heals  up,  the  ulceration  ceases,  and  the  stricture  is  some- 
times cured.  The  patient  being  in  lithotomy  position,  what 
I  do  is  simply  to  pass  my  finger  through  the  stricture ;  I 
then  introduce  a  long  straight  knife  along  my  finger,  and 
when  the  point  is  fully  above  the  stricture  I  cut  firmly  down, 
right  through  it,  in  its  whole  depth,  even  to  the  sacrum,  if 
necessary,  and  bring  the  knife  out  at  the  tip  of  the  coccyx. 
If  you  keep  the  median  line  the  bleeding  is  but  trifling,  and 
the  whole  of  the  diseased  structure  will  have  been  cut 
through. 

So  rapidly  beneficial  is  this  operation,  that  in  forty-eight 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  1 77 

hours  I  have  often  seen  night  sweats  arrested,  and  a  patient 
who  seemed  about  to  die  rally  and  eat  and  drink,  and  get 
well  from  that  moment ;  morbific  discharges,  instead  of 
being  absorbed,  run  out,  and  the  patient  is  not  poisoned. 
The  wound  should  be  well  syringed,  and  the  parts  kept  per- 
fectly clean.  I  always  use  dry  absorbent  cotton  wadding  as 
the  dressing,  and  I  only  want  my  patient  washed,  at  most, 
twice  in  the  day;  too  frequent  use  of  any  fluid,  carbolized 
or  not,  soddens  and  weakens  the  granulations  ;  if  you  want 
these  cases  to  do  well,  dry  dressings  are  those  I  advise  you 
tc  employ. 

Many  of  these  patients  have  done  well,  and  I  have  had  per- 
manent cures,  but  others  have  failed,  and  I  have  seen  a 
return  after  even  three  or  four  years.  In  the  after-treatment 
I  often  place  a  tube  in  the  wound,  keeping  it  in  at  night, 
which  tends  to  prevent  contraction, 

.  More  of  the  seventy  cases  would  have  been  subjected  to 
colotomy,  but  often  it  is  difficult  to  get  the  patient  to  con- 
sent, as  I  think  it  proper  to  put  fairly  before  the  sufferer  the 
disadvantages  as  well  as  the  advantages  of  the  operation. 

Many  cases  were  treated  by  dilatation,  assisted,  in  some 
instances,  by  small  incisions  ;  great  care  and  pains  are 
required  in  the  treatment  by  dilatation,  but  it  may  be  satis- 
factory, and  I  will  relate  some  cases  in  which  it  was  emi- 
nently so.  Stricture  of  the  rectum,  however,  is  a  disease 
infinitely  more  uncertain,  more  prone  to  relapse,  and  more 
difficult  to  treat,  than  stricture  of  the  urethra.  In  some  few 
cases  immense  good  resulted  from  the  administration  of 
iodide  of  potassium  and  mercury;  but,  on  the  other  hand, 
often  when  it  was  expected  to  benefit,  no  curative  result 
followed.  On  the  whole,  therefore,  I  place  no  faith  in  spe- 
cifics. 

I  think  it  is  very  advantageous  to  compare  the  results  of 
our  hospital  with  our  private  practice,  so  different  are  the 
patients  in  many  respects — their  habits,  the  food  they  take, 
the  houses  they  inhabit,  their  cleanliness,  sobriety,  the  com- 
paratively early  stage  of  the  malady  at  which  they  seek  good 
advice — that  one  often  finds  the  success  in  private  practice 
so  much  greater  as  to  be  really  astonishing.  I  shall  pro- 
ceed, as  shortly  as  I  can,  consistent  with  clearness,  to  give 
the  heads  of  cases  treated  in  private  by  me  during  the  past 
few  years.  Time  prevents  my  pushing  my  researches  fur- 
ther back  than  the  beginning  of  1876. 

Case  i. — Female,  married,  37.     No  children,  no  miscar- 


J78        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

riages  ;  stricture  about  three  inches  up  the  rectum  ;  ulcera- 
tion both  below  and  above  it ;  no  history  of  syphiUs  at  all ; 
never  had  any  sores  nor  discharge,  more  than  a  little  whites; 
has  no  pain  except  such  as  arises  from  straining  and  fre- 
quent desire  to  visit  the  closet.  The  husband,  perfectly 
willing  to  clear  up  the  question,  examined.  Never  had 
syphilis,  but  had  gonorrhoea,  but  not  since  his  marriage, 
eight  years  ago  ;  never  had  any  soft  sore  or  enlarged  glands 
in  groin.  No  scars  on  penis  or  in  groin.  The  disease  his 
wife  suffered  from  was  complained  of  about  five  years  ago  ; 
has  had  advice  and  bougies  passed.  I  thought  it  advisable 
to  divide  the  stricture  in  several  places,  and  keep  in  a  tube 
at  night.  Various  plans  of  treatment  were  employed,  with 
the  result  of  a  cure  in  nine  months  ;  good  reason  to  believe 
she  remains  well. 

Case  2. — Female,  married,  27,  Had  children  and  mis- 
carriages; at  her  last  two  confinements  children  alive  and 
appear  well.  Husband  contracted  syphilis  since  his  mar- 
riage ;  secondaries  followed,  and  his  wife,  then  encientey 
became  syphilitic;  child  died  a  few  weeks  after  birth  ;  it 
seemed  healthy,  but  feeble.  She  was  treated  then,  by  her 
medical  man,  for  secondary  syphilis.  Ulceration  and  stric- 
ture two  inches  from  anus  ;  no  symptoms  of  syphilis  now. 
She  suffers  much  from  the  bowels.  Careful  dilatation  and 
treatment  of  ulceration  made  her  quite  comfortable,  but  I 
feel  sure  to  this  day  she  is  not  quite  well.  Seen  with  Dr.. 
Smith,  of  Blackfriars. 

Case  3. — Female,  married,  30.  Constitutional  syphilis, 
acquired  from  the  husband.  No  miscarriages ;  but  two 
children  had  syphilis;  were  treated,  and  are  now  living. 
Examination. — Almost  impassable  stricture;  obstruction  so 
great  that  I  performed  colotomy,  the  late  Mr.  T.  Carr 
Jackson  assisting  me  ;  result  good,  but  continued  discharge 
from  the  rectum  and  the  stricture  very  tight.  I  have  been 
seeing  this  patient  occasionally  for  the  last  four  years.  The 
husband,  a  dissipated  man,  has  had  all  kinds  of  venereal 
disorders. 

Case  4. — Female,  married,  48.  No  constitutional  syph- 
ilis, and  has  never  had  any  symptoms.  Husband  healthy, 
and  says  he  never  had  any  venereal  affection  of  any  kind; 
married  very  young,  his  wife  being  not  nineteen.  Eldest 
child  eighteen,  and  all  family  healthy.  Examination. — 
Stricture  and  some  ulceration,  two  and  a  half  inches  from 
anus;  good  deal  of  pain  and  straining.     Slight  division  and 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.         1 79 

careful  dilatation  effected  a  cure  in  five  months.  I  am 
informed  that  this  patient  has  continued  well  since. 

Case  5. — Female,  married,  38.  No  symptoms  of  consti- 
tutional syphilis;  has  healthy  children;  very  painful  annular 
stricture  near  anus  ;  some  swollen  flaps  of  skin  extrude  ; 
ulceration  extending  for  an  inch  and  a  half  upward.  The 
husband  confesses  to  syphilis,  but  considered  himself  as 
quite  well  years  before  his  marriage;  has  no  symptoms  now; 
division  of  the  stricture,  blue  ointment  with  opium  to  ulcer- 
ation and  careful  dilatation  cured  her  in  about  two  years. 
I  have  not  heard  of  any  relapse. 

Case  6, — Female,  married,  37.  Stricture  and  ulceration 
rather  severe;  stricture  one  and  a  half  inches  from  anus; 
suffers  much;  has  dimness  of  vision,  which  I  found  to  be 
caused  by  iritis;  has  syphilitic  rash;  rupial;  is  very  cachectic 
and  feeble;  one  child,  nine  years  old,  quite  healthy.  Her 
husband  was  under  my  care  about  twelve  years  ago,  for 
indurated  sore ;  moderate  mercurial  treatment  for  six 
months;  all  symptoms  gone,  and  left  off  medicine.  Seen 
again  after  nine  months,  with  secondary  rash,  rather  scaly, 
and  sore  throat;  mercurial  treatment  again;  hydr.  cum.  cret. 
at  bedtime,  and  blue  ointment  between  the  toes;  very  soon 
well,  and  would  not  take  any  more  medicine.  Came  to  me 
four  years  after,  to  consult  me  about  the  propriety  of  mar- 
rying. On  careful  examination  I  could  find  no  evidence  of 
syphilis,  so  thought  he  was  justified  in  doing  what  he  liked. 
He,  soon  after  I  saw  him,  married,  and  the  only  child,  born 
fifteen  months  after  marriage,  was  healthy,  and  has  continued 
so.  To  return  to  the  wife  :  three  years  after  her  marriage 
she  had  a  rash  and  sore  throat.  She  was  treated  by  her 
medical  attendant  with  iodide  of  potassium,  and  she  quickly 
recovered;  the  husband  during  this  time  had  flying  attacks 
of  syphilis,  for  which  he  saw  me  two  or  three  times,  but 
took,  by  his  own  prescription,  iodide  of  potassium  and  sar- 
saparilla,  This  went  on  until  the  wife,  having  severe  bowel 
symptoms,  was  sent  to  me.  The  treatment  consisted  of 
mercury  and  iron;  the  stricture  was  a  little  dilated,  and  she 
was  sent  to  the  seaside;  great  improvement  took  place  in 
general  health;  the  iritis  -got  rapidly  well,  and  the  stricture 
was" much  modified  by  gentle  dilatation;  the  ulceration  also 
healed  in  great  measure,  so  that  she  suffered  but  little,  and 
the  bowels  acted  only  about  twice  in  the  day.  The  husband 
denied  any  fresh  infection  since  his  marriage;  slight  crops 
of  secondary  character  were  frequent,  and  he  on  one  occa- 


l8o        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

sion  had  an  indurated  crack  at  the  orifice  of  the  urethra. 
The  wife  eventually  was  quite  cured.  I  have  related  the 
above  somewhat  in  detail,  as  one  has  rarely  so  good  an 
opportunity  of  watching  such  a  case  so  long. 

Case  7. — Female,  36,  married  many  years.  Sent  me  by 
Dr.  Playfair.  Husband  says  never  had  syphilis;  no  symp- 
toms in  his  wife.  Stricture  two  and  a  half  inches  from  anus; 
slight  ulceration;  a  very  feeble  woman;  never  any  children; 
tendency  to  lung  affection.  Phthisis  in  family;  has,  from 
soon  after  marriage,  suffered  from  inflammation  of  the 
uterus,  and  has  now  a  fibroid  in  its  posterior  wall.  Has  a 
very  spasmodically  contracted  sphincter,  and  the  stricture  is 
long,  so  that  one  cannot  feel  the  extent  of  it ;  despite  all 
treatment  this  case  went  on  to  total  obstruction,  and  colotomy 
was  performed.  The  case  did  well ;  duration  of  stricture  at 
least  ten  years. 

Case  8. — Female,  married,  set.  45,  no  children.  No  his- 
tory at  any  time  of  syphilis.  Sent  me  by  Mr.  Burton,  of 
Blackheath.  Stricture  and  slight  ulceration  three  inches  up 
from  anus;  no  symptom  of  present  or  past  syphilis  in  patient 
or  husband;  great  relief  in  six  months;  treatment  by  dilata- 
tion and  mercurial  ointment.  Saw  this  patient  lately,  and 
she  remains  well. 

Case  9. — Female,  set.  50  ;  this  lady  came  from  Philadel- 
phia to  be  under  my  care,  History  very  doubtful,  but  has 
had  many  and  healthy  children,  and  several  difficult  labors  ; 
no  deaths;  no  miscarriages;  children  nearly  grown  up.  Very 
bad  stricture  and  ulceration;  linear  rectotomy  in  the  median 
line;  tubes  kept  in  for  weeks:  eventually  a  very  perfect  cure; 
stayed  six  months  in  England,  and  went  away  without  any 
tendency  to  contraction.  I  heard  from  this  patient  a  few 
years  ago;  after  she  left  my  care  she  continued  perfectly  well. 

Case  10. — Female,  married,  aet.  37.  No  family;  the  wife 
of  a  medical  man.  Stricture  near  anus;  ulceration,  swollen 
tabs  of  skin,  ichorous  discharge.  The  husband  had  a  hard 
sore  and  secondar5''  symptoms  not  long  before  marriage,  and 
he  knew  he  had  affected  his  wife,  whom  he  treated  from 
time  to  time.  Now,  after  an  interval  of  about  seven  years, 
the  first  symptom  appeared  in  his  wife,  the  husband  at  the 
same  time  showing  mucous  sores  on  the  lip  and  anus. 
Treated  for  a  long  time  by  specifics  and  local  treatment, 
including  division  of  the  stricture,  but  with  only  great  relief 
maintained  by  constantly  wearing  a  tube  ;  no  permanent 
cure,  I  fear,  will  be  effected. 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  iSl 

Case  ii. — Female,  married,  ast.  29.  Severe  ulceration; 
stricture  two  inches  up  the  rectum  ;  recto-vaginal  fistula. 
Husband,  a  very  dissipated  man,  confesses  to  have  had 
syphilis  and  gonorrhoea  many  times.  The  wife  had  tertiary 
sores  on  legs;  mucous  papules;  nodes  on  head;  very  cachec- 
tic and  feeble;  small  doses  of  mercury  were  given  twice  in 
the  day,  with  iodide  of  potassium  and  arsenic,  with  decoc- 
tion of  cinchona;  good  diet  and  fresh  air  soon  restored  her 
health,  and  attention  was  bestowed  on  the  stricture  ;  it  was 
divided  in  several  places  very  lightly  and  a  tube  worn,  but 
the  tenderness  defeated  all  the  treatment;  she  could  not 
retain  anything.  Suppositories  or  sedative  injections  were 
at  once  returned  and  pain  was  increased.  Her  health  again 
broke  down,  and  as  a  last  resource  colotomy  was  performed, 
but  she  lived  only  three  months;  relieved  from  pain,  but 
never  rallied. 

Case  12. — Female,  married,  set.  60  (widow).  Stricture  a 
little  way  up  the  bowel,  one  and  a  half  inches;  slight  ulcer- 
ation. Has  many  children  grown  up,  healthy;  only  for  a 
few  years  suffered  discharge;  frequent  going  to  stool  and 
general  decline  of  health.  Sent  to  me  by  Mr.  Sloman,  of 
Farnham.  Division  and  dilatation  of  stricture;  mercurial 
and  opiate  treatment  of  the  ulceration;  wearing  a  tube  at 
night  effected  a  great  improvement;  in  fact,  I  think  there  is 
every  reason  to  hope  for  a  cure.  I  have  since  heard  of  this 
lady  doing  well. 

Case  13. — Female,  unmarried,  set.  55.  Sent  to  me  by  the 
late  Dr.  Lockhart  Clarke.  For  many  years  has  suffered 
from  difficulty  in  the  bowels.  Examination. — Long  and 
tight  stricture,  two  inches  from  anus;  very  little  ulceration, 
but  considerable  roughness  near  the  anus,  evidently  the  scars 
of  old  ulceration;  the  index  finger  could  be  passed  through 
the  stricture  after  some  pressure.  The  history"  of  the  past 
showed  that  she  had  suffered  much  in  the  rectum,  pain, 
bleeding,  discharge  of  mucus  and  constipation  alternating 
with  diarrhoea.  Had  consulted  many  physicians,  and  taken 
enormous  quantities  of  medicine,  laxative  and  tonic  ;  she 
had  taken  great  care  of  herself,  lying  up  much.  Extreme 
caution  in  diet,  living  almost  solely  on  fish,  vegetables,  and 
fruit.  She  says,  on  the  whole,  constitutionally  she  is  better,  but 
increasing  difficulty  in  obtaining  relief  brought  her  to  me. 
The  case  I  considered  one  very  amenable  to  treatment  by 
dilatation  and  keeping  in  the  tube  at  night.  This  I  adopted, 
and  in  three  months  she  was  better  than  she  had  been  for 


l82         ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

many  years.  This  ulceration  and  stricture,  I  have  no  doubt, 
from  the  history,  arose  from  inflamed,  and  perhaps  suppu- 
rating, hemorrhoids  ;  the  submucous  tissue  got  affected, 
and  ulceration  and  stricture  resulted.  There  was  no  appear- 
ance of  any  tuberculous  tendency,  and  certainly  no  syphilis, 
acquired  or  hereditary.  I  cannot  see  why  in  many  cases  a 
similar  condition  may  not  result  from  constipation  and 
inflammation. 

Case  14. — Female,  married,  set.  34,  attended  with  Mr. 
Seymour  Haden.  Stricture  for  long  time ;  seen  by  Mr. 
Haden  one  month  ago,  when  the  obstruction  was  almost 
total,  and  she  had  constant  vomiting.  Mr.  Haden  got  a 
tube  through  and  relieved  the  obstruction.  No  history  of 
syphilis  or  struma  in  the  patient  or  husband;  the  question  of 
syphilis  in  my  own  mind  was  quite  settled  in  the  negative. 
I  attended  this  patient  for  some  time  and  she  much  im- 
proved. Her  husband  was  a  chemist,  and  with  a  little 
teaching  became  quite  skillful  in  passing  the  bougie.  I  lost 
sight  of  the  patient,  and  do  not  know  the  ultimate  result. 
My  opinion  was  that  the  cause  of  the  stricture  was  very 
severe  labors,  and  long  pressure  of  the  child's  head.  It  is 
not  uncommon  for  women  to  connect  their  bowel  trouble 
with  a  bad  or  instrumental  labor.  Although  I  should  not 
consider  this  a  common  cause  of  ulceration  and  stricture,  it 
ought  not  to  be  left  out  of  our  consideration. 

Case  15. — Female,  unmarried,  aet.  27.  Seen  by  me  in  con- 
junction with  Mr.  Aikin,  and  afterwards  with  Sir  James 
Paget.  Had  been  operated  upon  for  fistula,  and  ulceration 
followed,  severe  in  character  ;  got  better  and  worse.  Brigh- 
ton air  did  her  so  much  service  that  a  happy  result  was  anti- 
cipated, but,  however,  she  fell  back  again.  When  I  saw  her 
with  Mr.  Aikin  the  sphincters  were  quite  ulcerated  away  ; 
with  great  difficulty  the  finger  could  be  got  through  a 
stricture  two  inches  up  the  bowel.  The  history  led  me  to 
conclude  that  the  disease  was  tubercular ;  I  advised  imme- 
diate colotomy.  I  did  not  see  this  patient  until  four  months 
later,  when  she  was  much  worse  ;  abscesses  had  formed  in 
the  groin,  and  a  communication  was  established  between  the 
vagina  and  rectum  ;  her  condition  was  so  deplorable  that  an 
operation  was  undertaken,  only  as  a  means  o^  relief  by  turn- 
ing aside  the  faeces.  With  the  sanction  of  Sir  James  Paget 
and  Mr.  Aikin  I  performed  colotomy.  After  the  operation  I 
pointed  out  that  the  ulceration  ^ould  be  detected  from  the 
aperture  in  the  loin  by  passing  the  finger  toward  the  rectum. 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  183 

Her  history  from  this  period  was,  some  temporary  arrest  of 
the  ulceraton,  but  this  did  not  last  long,  and  soon  it  could 
be  seen  on  the  bowel  in  the  lumbar  opening.  Abscesses 
formed  in  all  directions,  and  burst  or  were  opened  in 
several  places,  so  that  the  interior  of  the  pelvis  could  be 
seen.  She  died  just  three  months  after  the  operation.  To 
a  certain  extent  relief  was  obtained,  but  not  so  much  as  I 
think  would  have  resulted  had  colotomy  been  earlier  under- 
taken.    The  ulceration  was  serpiginous  in  character. 

Case  i6. — Female,  married,  set.  34,  no  children,  was  seen 
by  me  in  consultation  with  Dr.  T.  B.  Crosby.  She  was 
suffering,  and  had  been  for  years,  from  tertiary  syphilis, 
necrosis  in  the  tibiae  having  taken  place  ;  had  not  undergone 
anti-syphilitic  treatment  for  lengthened  periods.  There  was 
ulceration  and  tight  stricture  in  the  bowel;  the  urethra  was 
ulcerated  through  in  nearly  its  whole  length,  so  that  incon- 
tinence of  urine  resulted  ;  some  communication  had  taken 
place  between  the  bowel  and  the  bladder,  as  wind  freely 
passed  on  her  making  water  or  on  introducing  a  catheter. 

Treatment  was  undertaken  by  passing  a  bougie,  keeping 
the  bladder  empty,  and  her  constitutional  powers  were  much 
improved  by  small  doses  of  mercury  and  tonics.  Result  of 
treatment  nugatory,  as  regards  the  incontinence  of  urine. 

Case  17. — Female,  married,  set.  47,  no  children.  Seen 
with  Mr.  Theophilus  Taylor.  Syphilis  undoubted,  tertiary 
scars  being  present ;  ulceration  of  rectum  and  stricture  ; 
very  much  discharge  ;  great  pain,  straining,  and  constant 
desire  to  go  to  stool ;  constitution  very  much  undermined. 
The  stricture  was  so  tight  that  division  was  made  in  dorsal 
median  line,  and  bougies  soon  after  introduced.  Tonics 
(iron  and  mercury  in  very  small  doses)  were  administered; 
aftor  long  treatment  great  improvement  took  place.  The 
wound  healed  and  the  ulceration  was  very  slight,  so  that  the 
discharge  became  almost  nil,  and  was  mucous  rather  than 
purulent.  She  was  instructed  to  pass  the  bougie  (very  short 
one)  herself  ;  she  could  safely  do  this,  as  the  stricture  was 
not  very  high  up.  When  last  seen  was  wonderfully  improved, 
but  had  incontinence  of  fseces  if  at  all  fluid.  Still,  the 
comfort  she  had  derived  from  treatment  was  most  marked 
and  satisfactory  to  her  as  well  as  to  her  medical  attendants. 

Case  18. — Female,  married,  aet.  42.  Three  children,  very 
healthy.  Sent  me  by  Dr.  Herbert  Davies.  Suffered  for  a 
long  time  with  constipation  and  straining  at  stool;  no  evacua- 
tion obtained  without  medicine  or  enemata  ;  rather  thin,  but 


184        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

not  unhealthy  looking ;  no  miscarriages ;  no  history  or 
appearance  of  syphilis.  Examination. — Found  tight,  annular 
stricture,  one  and  a  half  inches  from  anus;  ulceration  below 
the  stricture  as  well  as  slightly  above  ;  some  swollen  outside 
skin,  not  discharging.  The  stricture  proved  very  dilatable, 
so  the  use  of  the  bougie  enlarged  it  much  in  about  three 
weeks,  and  she  was  then  more  comfortable  than  she  had 
been  for  years.  The  ulceration  also  got  better  by  the  use  of 
a  bismuth,  morphia  and  pitch  ointment.  In  fact,  so  much 
better  was  this  patient  at  the  end  of  two  months  that  she 
has  not  visited  me  since. 

Case  19. — Female,  widow,  set.  59.  Sent  me  by  Mr.  Pinch- 
ing, of  Gravesend.  Long  troubled  with  her  bowels  ;  never 
passes  formed  motions,  always  in  small,  broken  pieces,  with 
blood  and  slime  on  them;  has  been  getting  thinner,  but  says 
her  health  is  fair,  and  if  she  was  comfortable  in  her  bowels 
would  be  quite  well.  Examination. — Stricture  tight,  /.  e. 
could  only  get  forefinger  through,  and  this  caused  much 
pain  ;  the  edge  of  the  stricture  was  ulcerated.  Many  years 
ago  had  been  operated  on  for  piles  at  a  London  hospital  ; 
she  was  in  poor  circumstances  then  ;  from  that  day  never 
had  perfect  comfort  in  the  use  of  her  bowels.  I  slightly 
divided  the  stricture  and  introduced  bougies,  gradually 
increasing  in  size,  and  by  the  application  of  ointments  the 
ulceration  gradually  got  better,  so  that  she  could  sleep  all 
night  with  a  bougie  in  the  stricture.  In  three  months  she 
was  quite  well  ;  no  trace  of  stricture  could  be  felt,  but  cor- 
rugations and  roughness,  showing  the  healing  of  the  ulcera- 
tion, remained.  I  saw  this  patient  more  than  a  year  after 
the  treatment,  and  she  continued  quite  well.  I  have  no 
doubt  this  stricture  and  ulceration  was  the  result  of  the 
operation  on  the  piles. 

I  have  seen  for  years  past  numerous  cases  of  ulceration 
with  stricture  result  from  operations  upon  the  rectum,  but  as 
this  condition  usually  takes  place  shortly  after  the  operation, 
and  is  manifestly  due  to  it,  I  have  not  given  any  histories  of 
such  cases,  although  they  frequently  take  a  great  deal  of 
time  and  trouble  to  cure. 

CASES  IN  PRIVATE  PRACTICE,  OF  ULCERATION  AND  STRICTURE 

IN    MALES. 

Case  i. — Male,  ast.  23.  In  the  army.  Had  a  hard  sore 
some  three  years  back  and  was  treated.  After  some  time  he 
suffered  from  pain  on  defecation,  and  he  went  to  a  surgeon, 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.         185 

who  said  he  had  syphilitic  sore  and  must  be  operated  upon, 
but  after  the  cutting  the  sore  became  worse,  and  he  came  to 
me.  I  found  the  sore  unhealed  and  inflamed,  and  suspect- 
ing more,  I  wnth  difficulty  passed  my  finger  up  the  bowel, 
when  I  found  that  above  the  sore,  which  had  been  divided, 
there  was  quite  an  inch  of  healthy  mucous  membrane  form- 
in  a  zone  around  the  bowel,  then  some  other  ulceration  in 
a  zone  an  inch  in  width.  He  had  no  other  sign  of  syphilis 
but  a  sore  throat.  Mercurial  ointment,  arsenic,  and  iron, 
with  cod-liver  oil,  as  he  was  weak  and  feeble,  soon  made  an 
improvement.  In  a  fortnight  a  bougie  could  be  passed, 
and  all  healed  in  about  eight  weeks. 

Case  2. — Male,  ast.  40,  married  ;  had  never  had  syphilis, 
but  told  a  strange  story,  that,  if  he  was  affected,  it  arose 
from  taking  a  Turkish  bath.  Very  bad  ulceration  extended 
two  inches  up.  Stricture  was  tight,  and  he  had  much  pain, 
and  got  no  relief  unless  he  took  large  doses  of  purgatives. 
Linear  rectotomy  and  twelve  months'  great  care  nearly  cured 
him.  I  have  not  seen  him  during  the  year  and  a  half  which 
has  elapsed  since  the  operation,  but  I  have  heard  he  is  not 
well. 

Case  3. — Male,  aet.  29,  unmarried.  Had  syphilis,  and 
was  treated  by  Ricord,  of  Paris,  for  eighteen  months,  and 
thought  himself  quite  well ;  had  lost  all  rash  and  all  symp- 
toms for  months,  and  then  discontinued  all  his  medicines. 
About  six  months  after  he  experienced  pain  and  straining  on 
defecation.  As  he  was  coming  to  England  he  was  recom- 
mended to  me.  On  examination  I  found  just  inside  the 
anus  ulceration,  with  stricture,  very  painful  to  touch  ;  he 
could  not  bear  the  bougie.  The  use  of  an  ointment  com- 
posed of  bismuth,  blue  ointment,  and  opium,  soon  relieved 
the  pain,  and  I  was  enabled  to  dilate,  and  he  kept  bougies 
in.  This  patient  had  never  had  soft  sores  in  his  life,  nor 
even  gonorrhoea.  He  was  not  a  strumous,  nor  in  any  way  a 
delicate  man.  The  case  ended  favorably,  showing  the 
desirability  of  early  treatment. 

Case  4. — Male,  aet.  28,  unmarried,  a  native  of  India  study- 
ing medicine  in  this  country.  Had  suffered  from  dysentery 
and  diarrhoea  frequently,  but  not  severely,  in  his  own  country. 
Has  been  in  England  two  years  and  no  severe  attack  ;  in 
fact,  much  better  here  than  abroad.  About  one  month  ago 
felt  pain  on  defecation,  but  took  a  little  laxative,  and  found 
himself  better,  but  still  straining  was  frequent,  with  mucous 
and  occasional  blood.    He  came  to  me  ;  he  was  a  small,  thin. 


1 86        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

agile  man  of  more  than  average  intelligence.  Exa^nina- 
tion. — I  found,  three  inches  from  anus,  a  stricture  through 
which  only  a  small  bougie  would  pass.  Injections  of  opium 
and  starch  in  very  small  quantities  relieved  the  pain,  and 
allowed  me  to  increase  the  size  of  the  bougie.  The  stricture 
proved  very  amenable,  and  he  was  soon  restored  to  perfect 
comfort,  and  his  health  improved.  I  advised  the  continuance 
of  a  short,  small  bougie. 

Case  5. — Male,  unmarried,  but  who  intended  to  be  married, 
came  to  me  about  an  uneasy  sensation  in  the  rectum,  fre- 
quent diarrhoea,  and  straining;  occasionally  mucus  passes  in 
abundance;  was  treated  for  syphilis,  with  mercury  in  various 
forms,  by  one  of  our  best  surgeons  ;  and  now  he  felt  himself 
quite  well.  Examination. — Stricture  an  inch  and  a  half  from 
anus  ;  above  the  stricture  ulceration.  The  stricture  was 
hard  but  the  ulceration  very  soft.  Had  no  other  venereal 
affection  since  the  sore.  Health  fair.  I  found  it,  after  a 
time,  necessary  to  divide  the  stricture  freely;  then  the  ulcera- 
tion, by  treatment — topical  chiefly — rapidly  improved,  and 
after  nine  months  he  was  fairly  well.  During  my  treatment 
I  sent  him  to  Aix-la-Chapelle,  as  he  had  a  return  of  syphilitic 
sore  throat  and  rash,  to  be  under  the  care  of  Dr.  Brandish 
and  undergo  baths  and  mercurial  inunction.  He  came  back 
without  any  rash,  and  with  his  health  greatly  improved.  The 
ulceration  had  then  not  healed,  but  soon  after  he  got  quite 
well,  and  I  think,  remains  sound. 

Case  6. — ^Male,  single,  aet.  47,  retired  captain  in  the  army; 
very  bad  stricture  and  ulceration;  feeble,  and  much  worn 
and  emaciated;  says  never  had  any  venereal  affection  what- 
ever, and  as  he  had  no  reason  for  deceiving  me,  and  I  could 
find  no  trace  of  syphilis  anywhere,  I  believed  him.  For  some 
years  he  had  this  affection,  and  when  in  the  army  in  India 
he  was  treated  with  bougies,  but  with  very  slight  advantage. 
No  history  of  phthisis  in  his  family.  Suffers  very  much.  A 
careful  course  of  bougies,  keeping  them  in  when  he  could 
bear  them,  a  little  division  of  the  strictures  (for  there  were 
two)  in  several  places,  gradually  got  him  into  comfort,  but 
cure  seemed  hopeless.  He  returned  to  me  a  few  months 
back  and  finding  him  suffering  much  I  proposed  colo- 
tomy,  to  which  he  acceded.  The  operation  has  proved  a 
signal  success,  and  he  is  alive  now. 

Case  7. — Male,  single;  said  to  have  had  only  soft  sore, 
but  as  copious,  rash  followed,  I  am  fain  to  believe,  although 
the  diagnosis  was  made  by  one  of  our  greatest  syphilograph- 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  187 

ers,  that  an  error  was  fallen  into.  Two  years  after  this  sore 
he  suffered  pains  on  defecation  and  came  to  me.  On  exam- 
ination I  found  stricture  and  ulceration  commencing  one 
inch  from  the  anus,  which  outside  appeared  normal.  The 
stricture  was  annular,  and  I  divided  it  in  several  places  and 
cautiously  dilated.  Blackwash  lotion  benefited  the  ulcera- 
tion, but  iodoform  did  most  good,  and  he  was  soon  well.  I 
advised  the  use  of  the  bougie  once  in  the  week  for  some 
months. 

Case  8. — Male,  set.  26,  lieutenant  in  the  army  ;  no  history 
of  syphilis  or  any  venereal  disease  whatever.  Ill  about  nine 
months.  Saw  this  patient  with  Sir  James  Paget,  who  agreed 
with  me  in  the  opinion  that  the  disease  was  strumous.  When 
I  first  saw  him  he  had  a  very  tight  stricture  close  to  the  anus. 
This  I  divided  and  dilated  only  to  find  another  stricture 
three  inches  higher  up,  and  plentiful  soft  ulceration  between 
the  two  strictures.  Local  and  general  treatment  failed  to 
do  good;  a  voyage  of  some  months'  duration  had  a  like 
result.  When  he  returned  he  was  seen  in  conjunction  with 
me  by  Sir  William  Gull,  whose  opinion  coincided  with  Sir 
James  Paget's  and  my  own.  He  is  still  being  watched,  and 
on  the  whole  is  better,  but  frequent  diarrhoea,  straining,  dis- 
charges of  blood  and  mucus  still  occur.  He  had  never  had 
dysentery  nor  habitual  diarrhoea. 

Case  9. — Male,  set.  37,  married.  History  of  soft  sores 
under  prepuce  and  buboes,  and  suppurating.  No  hardness 
observed,  and  no  eruption  or  symptoms  of  constitutional 
syphilis  known.  Healthy  looking,  strong  man.  An  inter- 
val of  eight  months  elapsed  from  the  cure  of  his  soft  sores 
until  he  complained  of  passing  blood  and  mucus  with  pain, 
per  anum.  This  went  on  for  some  time,  and  he  treated  it 
as  piles,  taking  laxative  medicines  and  using  lead  ointment. 
Finding  no  benefit  he  was  sent  from  the  country  to  me. 
The  history  was  given  so  truthfully  that  I  could  not  doubt 
his  words.  He  had  no  symptoms  of  syphilis,  but  he  showed 
me  a  wound  in  the  groin  where  one  bubo  was  opened.  Qn 
examining  the  rectum  I  could  only  just  pass  my  finger 
through  the  stricture,  and  I  found  ulceration  above  it,  but 
no  trace  of  any  below;  he  had  small  external  piles,  but  no 
ichorous  growths.  The  treatment  was  slight  division  of 
stricture,  wearing  a  bougie  all  night  smeared  with  bismuth 
and  morphia  ointment,  to  keep  the  bowels  open  by  the  lico- 
rice powder  (Pharm.  German),  to  avoid  all  alcohol  and 
meat,  and  to  live  on  farinaceous  food   and  plenty  of  milk. 


l8S        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

Success  soon  crowned  this  treatment,  and  in  three  months 
he  was  quite  convalescent. 

Case  io. — Male,  set.  46,  first  officer  in  American  line  of 
steamships.  Has  suffered  for  years  in  his  bowels,  terrible 
constipation,  and  passed  motions  with  blood;  much  pain  and 
/requc-nt  going  to  stool:  been  treated  for  piles,  and  ahvays 
took  sulphur,  from  which  he  derives  considerable  benefit. 
Very  strong,  healthy,  steady  man.  Never  had  any  venereal 
disease  at  all.  Steadfastly  held  to  this  statement.  Did  not 
mean  to  say  that  he  had  run  no  risk,  but  had  been  fortu- 
nate. I  could  detect  no  sign  of  syphilis,  no  bubo,  scars,  or 
rash.  Examination  of  rectum. — Tight  stricture  an  inch 
and  a  half  from  the  anus,  and  there  was  ulceration  above 
and  below  the  stricture.  I  divided  the  stricture  and  dilated, 
keeping  in  a  vulcanite  tube  for  several  days.  He  became  so 
much  better  that  at  the  end  of  three  w^eeks  he  again  went  to 
sea,  using  at  night  a  small  tube,  which  he  could  wear  with 
comfort  and  no  danger.  I  saw^  this  patient  many  times,  and 
found  him  always  better,  but  a  slight  discharge  of  mucus 
still  continued,  but  as  his  constipation  was  removed  and  he 
suffered  no  pain,  he  became  quite  satisfied  wdth  the  result. 
The  only  thing  that  radically  benefited  his  constipation  after 
the  operation  and  dilatation  was  a  dinner  pill,  which  he 
took  every  other  day,  composed  of  extract  nux  vomica, 
ipecacuanha,  and  compound  rhubarb  pill. 

From  a  study  of  the  history  of  nineteen  females  treated, 
and  watched  afterwards  for  some  time,  it  appears  that  seven 
had  undoubted  signs  of  constitutional  syphilis,  and  twelve 
had  neither  the  symptoms  nor  history  of  any  form  of  vene- 
real disease;  thus  there  w^as  much  less  undeniable  syphilis  in 
private  than  in  hospital  practice.  In  the  non-syphilitic 
patients,  the  ulceration  was  most  tuberculous.  Tw^o  patients 
ascribed  the  disease  of  the  bowel  to  many  difficult  labors.  I 
cannot  see  why  injuries  during  labor  should  not  be  a  source 
of  ulceration  ending  in  a  constriction;  in  fact,  I  wonder  we 
do  not  oftener  meet  with  instances  in  w^hich  this  cause  alone 
can  be  assigned.  One  case  resulted  from  an  operation  per- 
formed upon  the  rectum  long  since. 

In  most  cases,  having  the  husband  before  us  to  interro- 
gate and  examine,  we  are  enabled  to  compare  his  condition 
wnth  that  of  his  w^ife.  I  am  confident  that  in  the  majority 
the  evidence  of  the  husband  was  to  be  depended  upon.  In 
Case  3,  which  was  one  of  the  worst  strictures  I  ever  saw, 
and  in  which  I  w^as  compelled  to  perform,  colotomy,  the'hus- 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM  189 

band  had  suffered  from  all  kinds  of  venereal  infection.  Case 
6  had  iritis  and  well-marked  syphilitic  rash.  I  knew  her 
husband  had  suffered  from  constitutional  syphilis,  as  I  had 
treated  him.  The  poison  probably  was  quiescent  at  the 
time  he  impregnated  his  wife,  as  the  child  was  born  healthy 
and  has  continued  so  up  to  nine  years  of  age.  Twenty 
months  after  the  child  was  born  the  mother  suffered  from 
syphilis  for  the  first  time.  The  husband  about  that  time 
consulted  me  for  slight  flying  attacks  of  secondary  symp- 
toms, and  he  said  there  had  been  a  crack  at  the  entrance  to 
the  urethra,  and  in  my  opinion  that  crack  inoculated  his 
wife;  she  was  not  under  my  care,  and  no  search  was  made 
for  any  sore,  and  it  was  not  until  seven  years  after  she  had 
become  syphilized  that  she  came  to  me.  In  four  cases  lum- 
bar colotomy  was  performed. 

A  few  words  about  the  male  patients,  who  were  ten  in 
number:  observe  in  private  practice  how  many  more  men  in 
proportion  to  women  than  in  hospital  practice.  Three-had 
decided  constitutional  syphilis.  One  had  doubtful  symp- 
toms. One  had  suffered  from  a  soft  sore  under  the  prepuce, 
accompanied  by  a  suppurating  bubo;  and  the  remainder, 
viz.,  five  patients,  had  no  syphilitic  or  venereal  taint.  Of 
these,  repeated  dysentery  was  probably  the  cause  in  one,  if 
not  two.  Two  resulted  from  tuberculosis  (my  opinion  in 
these  cases  was  sustained  by  Sir  James  Paget).  One 
resulted  possibly  from  the  hard  life  of  a  sailor;  bad  feeding, 
exposure  to  weather,  dysenteric  diarrhoea  at  times,  but 
usually  the  most  intractable  constipation;  his  rectum  for 
years  was  constantly  irritated  by  contracting  upon  hard  and 
dried  masses  of  faces.  In  such  a  case  injury  to  the 
mucous  membrane  could  not  be  an  unexpected  event.  It  is 
often  difficult  to  trace  the  cause  in  a  case  of  ulceration,  but 
really  such  conditions  as  I  have  described  must  sometimes 
be  either  predisposing  or  exciting.  In  one  case  only  was  I 
obliged  to  perform  lumbar  colotomy.  In  one  case,  also, 
Verneuil's  operation  was  done;  the  success,  however,  was 
more  than  doubtful,  as  I  have  heard  this  patient  is  still  suf- 
fering. I  have  found,  speaking  generally,  that  a-  fair  amount 
of  relief  is  more  frequently  attained  by  treatment  in  men 
than  in  women.  Various  reasons  will  suggest  themselves  to 
my  readers,  as  conditions  of  the  uterus,  ovaries,  vagina, 
coitus,  etc.  Lastly,  I  would  observe  that  complete  cures 
are  seldom  if  ever   obtained,  but  great  relief  is  not  uncora- 


IpO        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

mon,  and  in  favorable  cases,  by  proper  attention,  the 
patient's  life  may  scarcely  be  shortened  by  the  malady. 

On  summing  up  my  own  statistics  I  can,  in  short,  state 
that  in  women  forty-two  out  of  seventy-nine  had  suffered  or 
were  suffering  from  undoubted  constitutional  syphilis,  and 
in  twenty  males,  half  were  in  the  same  condition;  thus  out 
of  the  total  number  of  ninety-nine  patients,  fifty-two  (or 
more  than  half)  were  syphilitic.  This  is  a  greater  propor- 
tion than  I  have  seen  mentioned  before,  but,  as  far  as  I  can 
ascertain,  the  truth  is  stated.  What  causes  brought  about 
the  ulceration,  etc.,  in  the  forty-seven  patients  who  were  not 
syphilitic  ?  We  have  propounded  some  causes,  viz.  tuber- 
culosis (not  so  uncommon  as  generally  supposed),  dysentery 
and  diarrhoea,  usually  following  prolonged  residence  in 
tropical  climates;  obstinate,  long-standing  constipation; 
injuries  to  the  uterus  and  vagina  in  parturition;  operations 
on  the  rectum  in  persons  of  bad  constitution;  but  will  these 
causes  account  for  all  the  cases  ?  I  am  obliged  to  say  I  do 
not  think  so,  and  to  confess  in  the  majority  of  these  patients 
I  do  not  know  the  cause,  nor  have  I  been  able  to  trace  out 
any  definite  common  state  preceding  the  malady.  If  we 
could  answer  the  question  why  ulceration  and  stricture  is  so 
much  more  frequent  in  the  female  than  in  the  male,  we 
should  possibly  have  a  clue,  but  for  my  part,  I  cannot  see 
that  any  satisfactory  reply  has  been  given  to  this  question, 
nor  has  it  to  another  question;  why  is  epithelioma  compara- 
tively rarely  found  in  woman  ? 

In  connection  with  this  part  of  the  subject,  I  must  say  a 
few  words  about  the  view  entertained  by  some  French 
authorities,  and  also  by  eminent  American  surgeons,  viz., 
that  the  vast  majority  (some  say  all)  of  cases  of  stricture  and 
ulceration,  not  cancerous,  result  from  contamination  by  the 
discharges  from  "  soft  sores "  or  "  chancroids."  They 
scarcely  admit  that  constitutional  syphilis  has  anything  to 
do  with  the  cases  I  have  been  considering  in  this  chapter. 
When  a  former  edition  of  this  work  appeared,  I  well  knew 
that  Dr.  Gosselin,  of  Paris,  had  published  these  views,  but  I 
knew  also  that  his  conclusions  had  been  arrived  at  from  very 
few  observations;  that  another  explanation  of  his  cases, 
which  I  will  not  mention,  could  be  readily  found,  and  that 
his  theory  had  received  but  feeble  support  from  any  of  his 
confreres,  while  many  of  the  most  eminent  authors  on  syphilis, 
as  Ricord,  Fournier,  Molliere,  and  others,  had  altogether 
repudiated  his  doctrines.     These  I  deemed  sufficient  reasons 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  ipr 

for  not  discussing  the  views  in  question:  but  since  I  have 
received  a  monograph  from  Dr.  Erskine  Mason,  of  New 
York,  who  adopts  Gosselin's  views  in  their  entirety,  I  have 
without  prejudice  considered  the  subject,  and  observed  my 
cases  from  the  standpoint  Dr.  Mason  takes,  and  I  must  state 
that  I  am  not  by  any  means  convinced  by  Dr.  Mason,  though 
entertaining  a  very  high  sense  of  the  ability  and  spirit  with 
which  his  monograph  is  written. 

I  think  1  have  made  it  quite  clear  in  the  foregoing  pages 
that  in  both  sexes  the  most  intractable  ulceration  and  stric- 
ture of  the  rectum  may  arise  without  there  being  any  venereal 
element  whatever  in  its  causation,  and  I  think  I  am  not 
alone  in  this  view.  It  appears  from  Dr.  Mason's  statistics, 
as  well  as  my  own,  that  about  half  the*  patients  with  ulcera- 
tion and  stricture  "  have,  or  have  had,"  constitutional  syph- 
ilis. A  fair  inference  is,  I  think,  that  some  form  of  syphilis 
may  cause  the  rectal  lesion.  Post-mortem  examinations 
have  revealed,  in  addition  to  rectal  ulceration,  deposits  in  the 
liver,  lesions  of  the  brain  and  membranes,  and  diseases  ef 
bone;  at  least,  probably  all  these  resulted  from  the  same 
cause;  but  I  do  not  wish  for  one  moment  to  maintain  that 
in  every  case  when  syphilis  and  ulceration  of  the  rectum 
coexist  the  latter  is  caused  only  by  the  former. 

It  is  no  sound  argument  to  say  that  if  the  ulcerations  of 
the  rectum  were  syphilitic  they  ought  to  yield  to  the  usual 
anti-syphilitic  remedies,  because  it  is  well  know^n  that  the 
latest  syphilitic  manifestations,  or  the  sequelae  of  syphilis, 
are  commonly  not  amenable  to  specific  treatment,  whether 
they  occur  in  one  or  other  organ;  and  in  fact,  the  time  has 
passed  away  in  which  any  constitutional  treatment  could  be 
expected  to  have  much  effect. 

Dr.  Mason  says,  "  I  have  repeatedly  noticed  the  anus 
become  contracted  in  women  after  the  healing  of  several 
simple  chancroids  involving  this  portion  of  the  intestine."  I 
must  say  I  have  never  seen  such  a  thing  myself. 

How  can  the  discharge  from  a  soft  sore  get  into  the  anus 
and  thence  to  the  rectum  ?  by  the  discharge  running  down 
to  the  anus;  possibly,  but  I  should  say  rarely.  Through 
menstruation  ?  more  probably.  By  .direct  contact  from  the 
male  organ?  most  probably.  In  France  this  cannot  be 
uncommon.  I  trust  it  is  not  common  in  America.  I  cannot 
say  that  in  this  country  it  is  altogether  unknown,  but  I  hope 
and  think  it  is  inf?requent.  I  will  make  this  assertion  with- 
out fear  of  contradiction j  in  the  large  majority  of  ulcerations 


ig2         ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

of  the  rectum  the  disease  does  not  commence  at  the  anus, 
but  at  least  an  inch  up  the  bowel,  a  condition  I  would  say, 
quite  incompatible  with  the  theory  of  inoculation  from 
external  discharge,  but  in  accordance  with  what  one  might 
expect  when  the  discharge  was  implanted  by  direct  contact. 
Dr.  Mason's  own  statistics  bear  out  my  statement  as  to  the 
usual  site  of  the  ulcerating  stricture. 

Has  any  one  seen  soft  sores  on  any  part  of  the  body  caus- 
ing induration  and  contraction  of  tissues  ?  do  we  see  this  in 
soft  sores  under  a  long  prepuce  ?  Then,  once  more,  how 
does  phagedaenic  ulceration  accord  with  contraction  and 
fibroid  degeneration  of  tissue,  which  is  one  of  the  essential 
characteristics  of  advanced  ulceration  and  stricture  ? 

Dr.  Mason  asserts  that  he  has  seen  "  constriction  of  the 
rectum  follow,  and  that  very  shortly  after  the  healing  of 
chancroids  had  taken  place."  I  would  ask  is  this  a  patho- 
logical probability;  and  is  the/^.f//z^(:  necessarily  the/r^/^/i^r 
^oc  in  such  a  case  ? 

I  shall  but  cite  some  eminent  authorities  on  this  very  inter- 
esting subject,  as  space  is  wanting  for  further  argument  and 
observations.  Time,  I  am  sure,  will  dispel  all  doubt,  but  at 
present,  I  think,  we  may  safely  say  that  the  chancroid  theory 
does  not  account  for  the  majotity  of  strictures  and  ulcerations 
of  the  rectum. 

Ricord  has  expressed  the  opinion  that  many  cases  of 
stricture  were  caused  by  syphilitic  deposits  and  ulceration. 
Fournier  has  most  positively  asserted  that  stricture  and 
ulceration  of  the  rectum  were  commonly  caused  by  consti- 
tutional tertiary  syphilis,  and  most  rarely  by  local  contamin- 
ation of  any  kind.  Lancereaux.  in  his  book  on  "  Syphilis, 
Historical  and  Practical,"  states  that  gummata  have  been 
found  in  the  large  intestine,  and  although  inclined  to  agree 
with  Gosselin,  and  regard  these  "  contractions  of  the  rectum" 
rather  as  venereal  than  syphilitic,  yet  would  not  too  exclus- 
ively adopt  the  theory;  inasmuch  as  gummy  deposits  are 
found  in  other  parts  of  the  intestinal  canal,  there  is  no 
reason  why  they  should  not  occur  in  the  rectum.  The 
English  surgeons  most  experienced  in  syphilis,  almost  with 
one  accord,  adhere  to  the  constitutional  theory,  and  discard 
the  idea  of  the  local  origin  of  ulceration  and  stricture  of  the 
rectum.  I  have  spoken  to  scarcely  one  gentleman  who  has 
not  given  me  a  similar  answer  to  my  question  on  this  point. 

My  friend  and  former  colleague,  Mr.  James  R.  Lane,  at 
my  request  wrote  me  his  opinioii  on  this  subject,  and  I  ven- 


ULCERATION  AND  STRICTURE  OF 'THE  RECTUM.  I93 

ture  to  submit  that  few  men  have  had  greater  opportunities 
for  studying  the  matter  than  he.  Many  years  Surgeon  to 
the  Hospital  for  Diseases  of  the  Rectum,  the  worst  forms  of 
stricture  and  ulceration  are  perfectly  familiar  to  him;  for  a 
still  longer  period,  as  Surgeon  to  the  Female  Lock  Hospital, 
he  has  had  an  almost  unbounded  field  for  observing  every 
kind  of  sore  to  which  the  female  genitals  are  exposed,  and 
what  does  he  say  ?  "I  believe  that  the  ulcerated  strictures 
of  the  rectum  to  which  you  allude,  and  with  which  I  am  so 
familiar,  are  very  rarely,  I  am  almost  disposed  to  say  never, 
caused  by  primary  syphilitic  ulceration  of  the  nature  of  soft 
sores.  According  to  my  Lock  Hospital  experience,  by  far 
the  most  common  seat  of  such  sores  is  at  the  inferior  four- 
chette,  and  the  verge  of  anus.  They  get  well  in  due  course, 
under  simple  treatment,  like  soft  sores  generally  do  ;  some- 
times, when  situated  on  the  sphincter  ani,  they  produce  the 
pain  characteristic  of  *' anal  fissure,"  but  they  will  heal  all 
the  same  and  the  pain  will  disappear.  When  one  of  these 
sores  extends  into  the  rectum,  which  is  very  seldom  the  case, 
the  result  is  a  circumscribed  rectal  ulcer,  which,  with  treat- 
ment, and  especially  judicious  cauterization,  will  usually 
heal."  Mr.  Lane  further  guards  himself  against  being  sup- 
posed to  consider  all  bad  ulcerations  and  strictures  as  result- 
ing from  constitutional  syphilis.  In  Mr.  Lane's  observations 
I  most  heartily  concur;  my  experience  of  soft  sores  near  the 
anus  is  that  they  speedily  heal  under  proper  treatment,  and 
I  have  seen  many  cases  cured  in  a  few  days  by  cleanliness 
and  the  use  of  a  tartrate  of  iron  lotion,  and  though  these 
patients  have  been  seen  from  time  to  time  for  other  ailments, 
no  ulceration  or  stricture  of  the  rectum  has  been  found  to  ensue. 

Mr.  Walter  Coulson,  Surgeon  to  the  Lock  Hospital,  has 
never  seen  ulceration  and  stricture  result  from  a  soft  sore, 
nor  has  my  colleague,  Mr.  Alfred  Cooper,  who,  like  Mr.  Lane, 
is  Surgeon  both  to  the  Lock  Hospital  and  to  St.  Mark's,  and, 
therefore,  has  the  double  opportunity  of  noting  these  sores 
from  an  early  period  and  following  them,  if  they  came,  to 
the  Hospital  for  Diseases  of  the  Rectum  atterwards. 

Mr.  Christopher  Heath,  of  University  College  Hospital, 
has,  in  some  lectures  by  him  on  "  Diseases  of  the  Rectum," 
strongly  expressed  his  conviction  that  the  cases  we  have  been 
discussing  are  commonly  the  result  of  tertiary  syphilis.  Mr. 
Bryant,  in  his  "  Practice  of  Surgery,"  looks  upon  these  ulcer- 
ations and  strictures  "  as  mainly  syphilitic,"  and  only  thus 
notices  Goselin's  views  :  "  Foreign  authors  describe  chan- 


X94        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

croid  disease  of  the  rectum  venereal  but  not  syphilitic  ;  in 
this  country  it  is  hardly  recognized." 

There  are  no  maladies  more  baffling  to  the  surgeon  than 
ulcerations  and  strictures  of  the  rectum,  and,  as  I  have 
before  said,  they  are  often  quite  incurable,  and  nothing 
affords  relief  save  colotony.  This  operation,  however,  though 
doubtless  it  may  prolong  life,  should  not  be  resorted  to 
without  due  consideration,  because  one  cannot  fail  to  see 
that  in  many  cases  the  remedy  proves  a  most  objectionable 
one  ;  an  opening  in  the  left  loin  through  which  the  faeces 
escape  is  very  harrassing,  and  nothing  but  a  great  desire  to 
live  or  the  fear  of  immediate  death  would  lead  me  to  submit 
to  such  a  proceeding.  I  presume  that,  as  time  goes  on,  the 
patients  get  used  to  the  discomfort  and  loathsomeness  of 
their  condition.  My  patients  who  have  lived  long  seem  to 
have  had  some  pleasure  in  life  ;  indeed,  two  woman  were 
married  after  the  operation,  but  notwithstanding  such  facts 
as  these,  I  entertain  greater  repugnance  to  the  operation  than 
I  formerly  felt,  and  latterly  have  mostly  performed  it  as  a 
last  resource  or  for  total  obstruction.  It  is  not  quite  impos- 
sible, after  colotomy,  that  the  ulceration  and  stricture  may 
get  well,  and  then  the  wound  in  the  loin  might  be  closed ; 
this  I  have  once  done,  but  although  I  have  tried  I  have  never 
succeeded  again.  In  the  earlier  stages  of  ulceration  and 
stricture,  from  whatever  cause,  save  cancer,  treatment  care- 
fully selected,  judiciously  varied,  and  persistently  carried  out 
may  do  much  good,  and  in  favorable  cases  even  effect  a  cure, 
but  the  patient  must  have  faith  in  his  surgeon,  and  be  pre- 
prred  to  submit  to  long-continued  watching  even  when  much 
improved ;  if  the  sufferer  runs  about  from  one  doctor  to 
another  his  fate  is  sealed,  as  he  gives  neither  himself  nor  his 
surgeon  a  chance. 

In  cases  of  circumscribed  ulceration,  I  have  great  confi- 
dence in  the  efficacy  of  rest  in  the  recumbent  position,  and 
in  a  wholly  or  nearly  fluid  diet,  and  I  consider  milk  should 
be  the  essential  element  in  such  a  diet.  I  could  relate  many 
cases  where  I  have  really  cured  the  patients  with  very  little 
medication,  occasional  slight  applications  of  a  caustic  solu- 
tion, bismuth,  morphia,  and  a  gentle  regulation  of  the  bowels, 
having  fulfilled  all  the  indications.  These  patients  confined 
to  the  sofa,  and  fed  almost  entirely  on  milk,  often  improve 
in  general  health,  and  gain  weight.  If  cod  liver  oil  can  be 
taken  I  prescribe  it  as  an  aid  to  nutrition,  but  it  must  be 
taken  only  in  small  dosea 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.         1 95 


Fig.  8. 


When  the  ulceration  is  deep,  and  contraction  has  com- 
menced, the  disease  is  much  more  serious,  and  a  very  doubt- 
ful prognosis  should  be  given  ;  still,  in  all  cases  a  good  deal 
may  be  done,  and  hope  may  be  instilled,  if  only  the  patient 
will  give  up  to  all  treatment  for  a  more  or  less  lengthened 
period.  If  patients  walk  about,  stand,  sit,  and  attempt  to 
continue  their  business  transactions,  treatment  is  nearly 
always  rendered  inefficacous  ;  one  indiscretion  may  render 

nugatory  a  week's  labor.  In  these 
cases,  therefore,  rest  is  even  more 
important  than  in  ulceration  in  the 
earliest  stage. 

Often  the  ulceration  induces  such 
an  irritable  condition  of  the  rectum, 
that  nothing  will  be  retained,  neither 
any  injection,  suppository,  nor  oint- 
ment ;  directly  anything  is  intro 
duced,  uncontrollable  spasmodic 
expulsive  efforts  are  set  up,  and 
may  continue  long  after  the  offend- 
ing matter  is  rejected  ;  thus  great 
pain  is  suffered  and  the  part  itself 
damaged.  I  have  found  that  bis- 
muth and  charcoal  taken  internally 
will  generally  soon  overcome  this 
excessive  irritability.  Subcarbonate 
of  bismuth  may  also  be  tried  on  the 
mucous  membrane  itself,  by  means 
of  an  insufflator ;  this  continouusly 
used  may  soothe  the  rectum  and 
relieve  pain.  As  a  rule  I  prefer 
ointments  to  suppositories  or  injec- 
tions. The  little  instrument  of  which  a  diagram  is  given 
obviates  all  difficulties  of  introduction,  and  I  am  sure  irri- 
tates less  than  other  methods  of  medication  ;  all  kinds  of 
sedative,  opiates,  and  astringents  may  in  turn  be  tried.  I 
am  very  fond  of  thefollowing  formula,  and  have  seen  it  most 
efficacious  : — 


^ .    Bismuth.  Subnitratis 3  i j 

Hydrarg.  Subchloridi- = 3ij_ 

Morphias gr.  iij 

Glycerinae 3  i j 

Vaseline 1  j. 


M. 


196        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

This  is  a  ,very  sedative  application,  and  sores  seem  to  be 
benefited  by  it  speedily.  Subacetate  of  lead,  belladonna 
and  opium  will  be  found  serviceable;  all  sorts  of  astringents 
may  be  employed  ;  rhatany,  friar's  balsam,  zinc  (the  per- 
manganate), copper,  iron,  nitrate  of  silver,  etc.  The  last, 
carefully  used  in  not  too  strong  a  solution,  is  one  of  the  most 
admirable  applications,  often  inducing  in  an  ulcer  a  healthy 
appearance,  and  causing  granulation.  The  tartrate  of  iron 
I  also  employ  for  the  same  purpose.  Fuming  nitric  acid  or 
strong  carbolic  or  chromic  acids  applied  under  certain  con- 
ditions, are  potent  remedies  ;  they  often  allay  pain  and  start 
healing  processes  afresh,  but  they  arig  double-edged  weapons, 
and  must  be  used  with  great  discretion  and  with  a  distinct 
object  in  view.  In  ulceration,  when  the  least  stricture 
exists,  bougies  may  be  always  employed,  but  it  must  be 
remembered  that  to  do  any  good  the  greatest  gentleness 
must  be  practiced  by  the  surgeon  ;  indeed,  pain  ought  not 
to  be  caused,  although  considerable  discomfort  cannot  in 
most  cases  be  avoided.  A  bougie  of  too  large  a  size  should 
never  be  employed  ;  no  greater  mistake  can  be  made,  than 
to  suppose  that  the  larger  the  bougie  you  can  get  in  the 
better  ;  keep  below  the  size  that  can  be  well  borne,  rather 
than  at  all  above  it ;  in  the  one  case  good  may  ensue,  in  the 
other,  irritation  and  retrogression  are  sure  to  take  place  ; 
never  give  a  patient  an  ordinary  bougie  to  use  for  himself, 
if  the  stricture  be  more  than  two  inches  from  the  anus. 
I  have  now  seen  two  deaths  occur  from  patients  thrusting 
the  instrument  through  the  wall  of  the  rectum  ;  peritonitis 
immediately  set  in,  and  they  expired  in  great  agony.  Occa- 
sionally, when  the  constriction  is  only  about  an  inch  or  an 
inch  and  a  half  from  the  anus,  I  let  the  patient  have  a  short 
instrument  to  pass  and  wear  at  night,  if  its  introduction  can 
be  accomplished  without  any  severe  pain.  I  employ  vul- 
canite tubes  furnished  with  a  collar,  to  which  tapes  are  fast- 
ened, to  keep  them  in  the  bowel,  and,  at  the  same  time,  pre- 
vent them  escaping  into  the  rectum,  an  accident  I  have  more 
than  once  seen  occur ;  in  one  case,  indeed,  a  full-sized 
bougie  entirely  disappeared,  and  could  not  be  reached  by 
the  finger  in  the  rectum;  its  distal  end  could  be  felt  in  the 
transverse  colon;  fortunately,  after  a  few  trials,  I  was  able 
to  seize  it  with  a  pair  of  long  bullet  forceps,  and  withdrew  it 
from  the  bowel;  the  patient,  as  may  well  be  imagined,  being 
not  a  little  frightened.  When  strictures  are  slight,  and  not 
very  long,  but  annular,  a  division  in  a  few  places,  with  the 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  1 97 

knife,  followed  by  judicious  treatment  with  the  tubes,  may 
be  very  beneficial  and  even  curative.  The  division  I  usually 
make  at  four  points,  and  I  take  care  just  to  cut  through  the 
induration,  and  reach  the  healthy  tissues  beneath,  but  not  to 
go  deeper;  the  ]?owel  should  be  filled  with  well-oiled  lint  or 
wool  for  twenty-four  hours,  and  then  the  tube  introduced 
and  worn,  only  taking  it  out  for  the  bowels  to  act,  and  to 
wash  out  the  rectum  with  some  antiseptic  solution.  I  prefer 
Condy's  fluid,  very  dilute,  or  thymol.  I  am  of  opinion  that 
carbolic  acid  is  always  too  irritant  if  strong  enough  to  be  of 
any  service. 

Some  four  years  ago  a  young  gentleman,  set.  19,  came  to 
me  with  an  annular  stricture  about  an  inch  from  the  anus  ; 
division  as  I  have  described,  the  use  of  the  tube,  and  general 
treatment,  cured  him  in  six  months,  and  he  has  continued 
well  to  this  day. 

Continuing  to  consider  the  progress  of  these  cases,  we 
come  to  the  more  severe  kind,  where  the  ulceration  is  very 
extensive,  the  constriction  so  bad  that  there  is  great  diffi- 
culty in  obtaining  any  passage  through  the  bowels;  no  action 
taking  place  without  the  use  of  strong  purgatives  or  where, 
on  the  other  hand,  incontinence  of  faeces  renders  the  patient's 
life  a  burden  to  him.  The  lower  part  of  the  rectum  will  be 
now  merely  a  passive  tube;  all  elasticity  has  gone,  and  liquid 
faeces  run  away,  or  there  is  a  perpetual  leaking  of  semi-fluid 
motion ;  the  condition  of  the  sufferer  is  truly  pitiable  ; 
around  the  anus  large,  hard  growths  exist,  and  fistulous 
passages  pass  up  the  bowel,  opening  into  the  ulceration, 
most  frequently  below,  but  sometimes  above,  the  seat  of 
constriction.  These  fistulas  may  be  divided,  and  some  tem- 
porary relief  afforded.  If  in  such  cases  the  fistulas  run  high 
up  the  bowel,  and  the  tissues  are  very  dense,  I  much  prefer 
the  elastic  ligature  to  the  knife;  in  fact,  I  now  never  employ 
the  latter  in  such  a  case  ;  the  bleeding  is  sure  to  be  exceed- 
ingly free  at  the  time,  and  great  difliculty  is  found  in  arrest- 
ing it,  as  the  vessels  can  neither  retract  nor  contract.  The 
only  patient  I  ever  lost  from  haemorrhage  afrer  an  operation 
upon  a  fistula  was  a  young  and  delicate  man,  sent  to  me  from 
Ireland,  with  stricture  and  numerous  fistulas,  the  whole  tissues 
being  brawny  in  the  extreme.  At  the  operation  I  had  great 
difliculty  in  arresting  the  bleeding,  but  concluded  that  all 
was  safe  ;  unfortunately,  in  the  evening  there  was  a  recur- 
rence ;  and  my  colleague,  Mr.  Goodsall,  succeeded  in  stop- 
ping it  with  plugging  aud  styptics;  however,  on  the  third 


198        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

morning  a  sudden  gush  took  place,  and  the  man  died  at 
once.  The  induration  of  the  parts  prevented  the  appHca- 
tion  of  any  ligatures  ;  they  cut  through,  or  the  vessel  was  so 
deeply  placed  as  to  be  out  of  reach. 

In  these  later  stages  of  ulceration  no  good,  is  derived  from 
constitutional  treatment.  Mercury  in  any  form  does  harm. 
Iodide  of  potassium  is  unavailing.  Tonics  to  maintain  appe- 
tite and  give  tone  to  the  nervous  system  may  be  used,  and 
always  cod-liver  oil,  which  may  be  regarded  as  concentrated 
nourishment ;  one  need  not  say  that  good  feeding,  with 
nutritious,  but  not  bulky,  food,  is  required.  I  shall  discuss 
more  fully  lumbar  colotomy  in  my  chapter  on  cancer. 

Stricture  of  the  rectum  without  ulceration  is  a  somewhat 
uncommon  affection.  We  have  seen  how  stricture  takes 
place  after  or  in  conjunction  with  ulceration.  The  thicken- 
ing of  the  tissues  and  the  contractions  which  result  from  the 
attempts  at  repair  must  narrow  the  canal,  but  it  is  not  so 
easy  to  see  how  or  why  a  stricture  should  occur  ter  se.  The 
rectum  is  a  tolerably  large  tube  (not  like  the  urethra,  where 
a  very  little  deposit  is  sufficient  to  nearly  block  up  the  pass- 
age), and  a  considerable  thickening  might  take  place  without 
causing  any  great  obstruction. 

We  may,  perhaps,  suppose  that  inflammation  of  the  sub- 
mucous tissue  produces  a  deposition,  and,  besides  this,  or 
resulting  from  this,  there  is  a  spasm,  t  am  sure  this  is  often 
the  case  ;  I  have  seen  strictures  of  the  rectum  so  tight  that 
I  could  not  get  the  end  of  my  little  finger  into  them,  but 
when  the  patients  were  well  under  the  influence  of  chloro- 
form I  have  been  able  to  pass  one  or  two  fingers  through 
easily. 

How  inflammation  and  thickening  are  set  up  in  the  con- 
nective tissue  of  the  bowel  it  is  difficult  to  say.  It  may  be 
that  straining  to  evacuate  the  contents  of  the  bowel  forces 
down  the  upper  part  of  the  rectum  into  the  lower,  thus  caus- 
ing an  intussusception,  and  bringing  the  part  within  the 
grasp  of  the  sphincter  muscles,  and  I  have  often  thought 
that  this  condition  may  be  the  starting  point  of  the  irri- 
tation. 

I  have  in  some  few  cases  had  a  suspicion  that  the  long- 
continued  pressure  of  the  child's  head  in  labor  has  been  the 
exciting  cause,  bruising  of  the  bowel  having,  perhaps,  taken 
place. 

Possibly,  also,  inflammation  may  be  induced  by  the  pass- 
age of  very  dry  and  hardened  faeces,  though  doubtless  this 


ULCERATION  AND  STRICTURE  OF  THE  RECTUM.  I99 

condition  may  obtain  for  years,  as  it  often  does  in  old  peo- 
ple, without  producing  stricture. 

I  have  seen  one  case  in  which  the  frequent,  and  perhaps 
rather  rough,  use  of  an  enema  pipe  produced  a  stricture, 
This  occurred  in  an  elderly  lady  who  had  for  years  given 
herself  an  injection  daily.  She  did  not  at  first  suffer  from 
constipation,  but  she  had  been  recommended  an  enema,  and 
at  last  she  could  not  get  an  action  without  it.  I  thought  in 
this  instance  it  was  not  improbable  that  the  passage  of  the 
bone  tube  had  been  the  exciting  cause  of  inflammatory 
thickening  of  the  bowel. 

It  may  perhaps  be  said  that  I  have  assumed  inflammation 
to  be  the  cause  of  the  exudation  into  the  wall  of  the  bowel. 
I  must  confess  that  I  have,  for  I  have  rarely  been  able  to 
detect  decided  symptoms  of  inflammation  of  the  rectum  pre- 
ceding stricture.  I  have  constantly  asked  patients  whether 
they  have  at  any  time  suffered  from  pain,  sensation  of  burn- 
ing, diarrhoea,  dysentery,  or  discharge  of  matter  from  the 
bowel,  and  the  reply  has  most  usually  been  in  the  negative. 
On  the  other  hand,  I  have  seen  cases  of  long-continued 
proctitis,  especially  in  aged  people,  not  followed  by  stricture. 
The  coarse  symptoms  of  stricture,  viz.,  straining  and  diffi- 
culty in  discharging  the  motions,  have  been  already  described. 
It  is  stated  in  some  works  that  the  stools  are  thin,  long,  and 
pipe-like.  According  to  my  experience  this  is  not  usually 
the  case  in  true  stricture;  spasm  of  the  sphincter,  enlarged 
prostate  gland,  and  tumors  of  the  pelvis,  much  more  fre- 
quently give  rise  to  flattened  and  thin  motions.  The  most 
characteristic  feature,  in  my  opinion,  is  the  passage  of  num- 
erous very  small,  broken  pieces;  the  faeces  having  no  actual 
form,  and  looseness  often  alternating  with  this  lumpy  con- 
dition. The  discharge  in  simple  stricture  is  like  the  white 
of  an  unboiled  egg  or  a  jelly-fish,  and  is  passed  when  the 
bowels  first  act.  There  is  no  coffee-ground-looking  dis- 
charge, so  constantly  seen  in  ulceration,  nor  is  there  the 
morning  diarrhoea  which  we  get  in  that  complaint.  There 
is  very  rarely  any  pain  experienced  in  the  bowel  itself;  the 
symptoms  are  generally  referred  more  or  less  to  distant  parts, 
notably  the  penis,  perineum,  bottom  of  the  back,  the  thighs, 
beneath  the  buttocks,  and  occasionally  the  stomach.  Fortu- 
nately strictures  of  the  lower  bowel  are  generally  within 
reach  and  sight,  but  occasionally  they  are  found  high  up  in 
the  sigmoid  flexure,  or  still  more  distant  from  the  anus.  In 
these  cases  it  becomes  a  matter  of  great  importance  to  ascer- 


200        ULCERATION  AND  STRICTURE  OF  THE  RECTUM. 

tain  the  situation  of  the  obstruction,  but  this  is  a  question  I 
shall  not  enter  upon  here. 

A  stricture  of  the  rectum  resulting  entirely  from  muscular 
spastn  is  what  I  am  very  much  disinclined  to  believe  in.  I 
do  not  deny  that  such  a  condition  may  be  found,  but  to  me 
it  appears  to  be  very  improbable,  and  I  feel  confident  that 
in  many  of  the  supposed  spasmodic  strictures  there  is  really 
no  constriction  at  all.  The  operator  has  been  misled  by  the 
bougie  catching  in  a  fold  of  the  gut  or  against  the  promon- 
tory of  the  sacrum.  If  you  are  in  doubt  about  the  existence 
of  a  stricture,  you  should  use  long  and  very  elastic  enema 
tube,  and  inject  fluid  as  you  pass  it,  so  as  to  distend  the  gut 
and  remove  any  intussusception  of  the  upper  part  of  the 
rectum.  This  condition,  I  think,  has  often  been  mistaken 
for  stricture,  as,  unless  the  bougie  goes  directly  into  the 
aperture  of  the  descended  portion  of  the  gut,  it  gets  into  the 
sulcus  at  the  side,  which  is  a  cul-de-sac,  and  the  instrument 
cannot  be  made  to  pass.  I  have  satisfied  myself  on  several 
occasions  of  the  existence  of  this  source  of  error. 

For  some  years  past,  in  exploring  the  rectum  for  stricture, 
I  have  used  vulcanite  balls  of  different  sizes,  mounted  on 
pewter  stems  with  flattened  handles;  ,they  are  easily  bent 
into  any  form;  they  will  even  bend  in  the  bowel,  and  by 
their  use,  as  in  exploring  the  urethra,  you  may  make  certain 
of  detecting  a  stricture.  For  when  they  pass,  or  on  gently 
withdrawing  them,  the  ball  is  felt  to  come  suddenly,  and 
perhaps  with  some  difliculty,  through  the  constriction.  Its 
length  also  can  be  approximately  measured. 

In  cases  of  stricture  when  there  is  great  spasm  with  a 
small  amount  of  organic  disease,  much  good  may  be  done 
by  the  use  of  bougies.  Before  passing  the  bougie,  it  is  well 
to  inject  into  the  bowel  some  sedative,  as  opium  or  bella- 
donna with  oil,  and  to  use  a  stiff  lubricant  on  the  bougie 
(such  as  blue  ointment);  if  the  instrument  cannot  be  quickly 
passed,  it  is  better  not  to  persevere,  as  irritation  will  be  set 
up  and  damage  done;  once  set  up  the  spasm  and  all  your 
endeavors  may  be  frustrated;  the  stricture  must,  as  it  were 
be  surprised.  I  do  not  like  any  forcible  dilatation  in  these 
cases;  you  may  tear  or  split  the  stricture  with  Todd's  dilator, 
but  you  are  more  likely  to  get  ulceration  than  permanent 
benefit  to  the  stricture.  On  the  same  principle  I  should  not 
cut,  even  in  the  slightest  degree,  any  constriction  where  no 
ulceration  existed,  save  in  cases  I  will  describe.  If  the 
stricture  is  high  up,  the  use  of  Todd's  dilator  is  dangerous. 


Ulceration  and  stricture  of  the  rectum.       201 

I  have  seen  profuse  haemorrhage  follow  its  use,  and  the 
bowel  might  be  torn,  to  the  injury  of  the  peritoneum,  especi- 
ally in  women. 

In  these  cases  I  am  also  of  opinion  that  retaining  a  bougie 
or  tube  is  not  usually  advantageous;  you  may  produce  ulcer- 
ation, and  if  this  should  be  done  you  will  perhaps  irretriev- 
ably damage  your  patient.  Gentle  dilatation,  very  gradually 
increasmg  the  size  of  the  instrument,  is  the  only  safe  treat- 
ment. The  conical  bougie  is  a  good  form,  as  gentle  pressure 
induces  this  to  enter  the  stricture  more  easily,  but  you  should 
never  cause  pain,  and  you  may  be  sure  that  if  blood  or 
mucus  passes  after  your  manipulation,  your  patient  will  have 
little  to  thank  you  for. 

I  used  to  think  that  twice  in  the  week,  or  at  most  three 
times,  was  as  often  as  the  instrument  ought  to  be  used,  but 
in  obstinate  cases  its  daily  use  has,  in  my  more  recent  exper- 
ience, been  followed  by  greater  permanent  good.  Still,  in 
this  matter  every  case  must  be  judged  on  its  own  merits, 
bearing  in  mind  the  axiom  "never  irritate." 

A  bad  form  of  stricture,  fortunately  of  rare  occurrence,  is 
that  in  which  the  constriction  is  semicircular  or  annular,  and 
feels  to  the  touch  as  though  the  bowel  were  encircled  by  a 
cord.  These  strictures  are  so  resilient  that  even  if  dilated  to 
their  fullest  extent,  they  very  soon  return  to  their  previous 
state  of  contraction.  It  is  in  these  alone  that  I  consider 
division  advisable,  but  the  incisions  should  be  only  super- 
ficial, aijd  dilatation  should  be  commenced  on  the  day  fol- 
lowing the  operation. 

When  a  stricture  is  well  dilated  the  patient  generally 
experiences  the  greatest  amount  of  relief;  there  is  no  more 
straining  at  stool;  comfortable,  good-sized  motions  are 
passed,  and  many  anomalous  symptoms  vanish.  One  draw- 
back is  the  rapidity  with  which  all  strictures  are  apt  to  return; 
the  relief  afforded  is  even  much  less  durable  than  that 
obtained  in  stricture  of  the  urethra;  the  patient  should  there- 
fore be  warned  never  to  be  long  without  having  the  bougie 
passed,  and  certainly,  directly  any  of  his  old  symptoms 
recur,  at  once  to  obtain  treatment;  if  this  advice  be  acted 
upon,  but  little  fear  need  be  entertained  of  a  dangerous 
relapse 


202  CANCER    OF    THE    RECTUM. 

CHAPTER  XVIII. 

CANCER   OF    THE   RECTUM. 

There  are  very  few  parts  of  the  human  body  which  may 
not  be  attacked  by  cancer,  but  some  are  more  frequently 
affected  than  others,  and  the  rectum  is  one  of  the  favorite 
sites  of  this  disease.  Cancer  is,  m  the  vast  majority  of 
cases  a  fatal  disease,  and  when  the  rectum  is  the  part 
affected  it  usually  runs  its  course  in  about  two  years.  In 
many  instances  the  duration  of  life  is  much  less.  I  have 
watched  a  case  of  encephaloid  which  terminated  fatally  at 
the  end  of  four  months  from  the  earliest  symptom  of  its 
invasion.  Colotomy  was  performed  by  me  when  I  first  saw 
the  patient,  two  months  before  death;  but  in  my  opinion 
it  did  not  delay  the  progress  of  the  disease  one  day,  although 
it  afforded  relief  from  excruciating  pain.  On  the  other 
hand,  I  have  seen  a  case  of  scirrhus  on  the  anterior  wall  of 
the  rectum,  in  which  the  patient  lived  about  four  years 
and  a  half.     I  will  briefly  record  the  case. 

A  man,  of  not  at  all  unhealthy  appearance,  came  under 
my  care  at  St.  Mark's  Hospital  in  the  year  1865.  He  had 
suffered  more  or  less  from  symptoms  of  obstruction  in  the 
bowel  for  five  or  six  months.  An  examination  per  annum 
detected  a  hard,  solid  mass,  appearing  to  rise  from  the 
neighborhood  of  the  prostate  gland;  it  blocked  up  the  whole 
rectum;  the  surface  was  irregular,  but  not  ulcerated  at  all. 
I  thought  it  might  possibly  be  a  hydatid,  although  no  fluc- 
ti^ation  could  be  detected;  a  long  exploring  trocar  thrust 
into  it  did  not  reach  any  fluid.  He  had  suffered  entire  con- 
stipation for  twenty  days,  and  his  symptoms  were  so  urgent 
that  I  at  once  performed  colotomy.  He  returned  home  in 
six  weeks  feeling  very  well,  and  he  lived  for  four  years  and 
a  half,  dying  at  last  from  the  extension  of  the  disease  to 
the  bladder  and  consequent  exhaustion. 

Cancer  is  commonly  a  disease  of  middle  life,  but  I 
have  seen  encephaloid  rapidly  fatal  in  a  boy  of  seven- 
teen; and  some  years  ago  there  was  in  St.  Mark's  Hospi- 
tal, under  the  care  of  my  colleague  Mr.  Gowlland,  a  boy, 
not  thirteen,  with  cancer  of  the  rectum.  Scirrhus  and  epi- 
thelioma are  not  very  uncommon  in  old  people,  and  in 
them    usually   run    a    very    slow    course,  which    may    be 


CANCER    OF    THE    RECTUM.  203 

accounted  for  by  the  fact  that  in  old  persons  the  vital 
forces  are  sluggish. 

It  has  been  said  that  cancer  is  more  frequent  in  women 
than  in  men.  As  regards  the  rectum,  this  is  directly  the 
reverse  of  my  experience.  In  my  statistics  many  more  men 
are  victims  than  women. 

I  am  in  accord  with  those  who  do  not  consider  cancer  as 
an  hereditary  malady  ;  it  is  true  that  there  are  very  few 
families  in  which  cancer  has  not  appeared,  more  or  less 
remotely,  but  that  is  only  because  cancer  in  some  form  is  so 
common  in  human  beings.  Although  I  always  put  the  ques- 
tion, it  has  comparatively  rarely  happened  to  me  to  find  that 
the  father  or  mother,  or  even  grandfather  or  grandmother, 
has  suffered  from  the  disease.  Often  uncles  or  aunts,  or 
brothers  or  sisters,  and  still  oftener  cousins  and  more  dis- 
tant relations  have  suffered  from  cancer ;  but  the  question 
of  heredity  is  not  thereby  affected. 

Some  varieties  of  cancer  may,  in  their  early  stage,  be  only 
and  purely  local ;  but  I  am  afraid  that  stage  is  of  very  short 
duration,  and  that  the  above  statement  is  hardly,  certainly 
not  practically,  true  of  the  more  malignant  forms.  By  this 
I  mean  that  as  soon  as  a  growth  exhibits  itself,  so  as  to 
be  noticed  by  the  patient,  the  disease  is  already  constitu- 
tional, and  the  system  is  infected. 

As  a  rule,  cancer  of  the  rectum  is  most  horribly  painful, 
the  function  of  the  part  enhancing  the  suffering;  but  I 
have  seen  patients  in  whom  there  has  not  been  excessive 
pain,  particularly  in  the  early  period.  In  the  more  advanced 
stages  of  the  malady  the  pain  often  becomes  unremitting, 
from  the  fact  that  many  nerves  become  involved,  and  are 
pressed  upon  or  stretched,  the  neighboring  organs  thus 
becoming  seats  of  separate  pain,  even  if  they  are  not 
actually  touched  by  the  growth.  I  had  a  patient  with  can- 
cer, which,  commencing  in  the  rectum,  involved  the  whole 
cavity  of  the  pelvis,  and  pain  down  the  right  sciatic  nerve 
was  one  of  her  most  distressing  symptoms. 

The  forms  of  malignant  disease  described  are  epithe- 
lioma, scirrhus,  encephaloid,  colloid,  and  melanosis.  I 
think  I  have  placed  them  in  their  order  of  frequency.  I 
have  never  seen  a  melanotic  tumor  of  the  rectum.  I  have 
seen  many  colloid  tumors,  but  I  am  not  sure  that  ence- 
phaloid may  not  be  colloid,  or  pass  into  it.  From  niy  own 
clinical  observations  I  should  be  inclined  to  say  that  in  can- 
cer of  the  rectum  it  is  often  very  difficult,  if  even  possible, 


204  CANCER    OF    THE    RECTUM. 

to  make  any  distinction  between  epithelioma  and  broken- 
down  scirrhus.  I  have  seen  cancers  of  the  rectum  stony- 
hard  at  one  part  and  quite  soft  at  another. 

MaHgnant  growths  are  commonly  found  seated  within 
three  inches  of  the  anus,  the  most  rapidly  dangerous  being 
higher  up,  about  the  lower  portion  of  the  sigmoid  flexure. 
When  cancer  occurs  near  the  anus  it  may  extend  upward 
beyond  the  reach  of  the  finger,  but  more  frequently  it  does 
not,  and  the  whole  extent  of  the  disease  can  be  ascertained. 
It  is  but  rare  that  any  form  of  cancer  commences  at  the 
anus  itself — I  have  seen  some  cases  of  epithelomia,  but  com- 
paratively few — nor  as  a  rule  does  the  cancer  come  grad- 
ually down  to  the  anus;  in  the  very  latest  stages  it  may  do  so, 
but  this  is  the  exception.  When  it  comes  down  to  the  anus 
it  is  generally  mistaken  for  piles,  and  caustics  are  applied,  to 
the  aggravation  of  the  patient's  suffering.  There  is  some- 
thing peculiar  about  the  feel  of  cancer,  which  the  prac- 
ticed finger  rarely  mistakes,  even  for  simple  indurated 
ulceration.  I  think  it  is  many  years  now  since  I  mistook 
the  one  for  the  other.  There  is  also  a  peculiar  odor  which 
one  cannot  describe  but  which  once  recognized  will  rarely 
be  forgotten.      In  my  opinion  the  odor  is  pathognomonic. 

Scirrhus  and  encephaloid  commence  according  to  my 
clinical  experience,  in  the  submucous  tissue,  and  the  mucous 
membrane  may  for  a  time  remain  quite  smooth  and 
unaffected,  though  adherent  to  the  growth  beneath. 

In  epithelioma  the  mucous  membranes  seems  from  the 
first  to  be  the  seat  of  the  disorder,  and  even  when  the 
growth  and  thickening  have  become  considerable,  the  whole 
will  be  found  freely  movable  over  the  structures  beneath. 
In  scirrhus  and  encephaloid  this  is  not  the  case;  very  early 
in  the  disease  it  has  spread  more  deeply,  and  in  many 
instances  it  seems  very  immobile. 

Scirrhus  is  often  found  as  a  hard  tumor  seated  in  the 
rectum  over  the  prostate  gland,  and  although  it  may  not 
have  arisen  from  the  gland  itself  nor  invaded  it  at  all,  yet  it 
is  remarkably  adherent  to  it.  In  a  case  in  which  I  removed 
a  scirrhous  nodule,  about  the  size  of  a  large  cherry,  from 
this  situation  I  was  obliged  to  dissect  off  with  the  growth 
the  fibrous  capsule  of  the  prostate  itself.  On  microscopic 
examination  the  tumor  was  declared  to  be  true  scirrhus,  by 
my  friend  Dr.  Wm.  Ord.  The  patient  recovered  from  the 
operation  and  I  have  not  heard  of  him  since,  but  I  should 
expect  that  the  growth  will  almost  certainly  recur. 


CANCER   OF    THE    RECTUM.  205 

The  more  malignant  forms  of  cancer  do  not  exist  very 
long  in  the  rectum  before  they  poison  the  blood  generally, 
and  cause  secondary  deposits  in  the  lumbar  glands,  groins, 
liver,  etc.  The  aspect  of  countenance  which  so  often 
attends  the  cancerous  cachexia  is  very  usual,  and  seen  earlier 
in  cancer  of  the  rectum  than  in  the  same  disease  of  other 
parts.  In  cancerous  growths  high  up,  vomiting,  frequent 
and  severe,  is  an  early  symptom,  even  when  not  much 
obstruction  exists.  The  onset  of  cancer  in  the  rectum  is 
often  marked  by  very  trivial  symptoms,  hence  the  disorder 
comes  upon  you  as  a  surprise.  A  patient  may  come  into 
your  consulting  room  complaining  of  no  more  than  a  little 
uneasiness  in  the  bowel  or  a  slight  morning  diarrhoea.  He 
may  look  thoroughly  healthy  and  strong,  and  may  really 
think  himself,  save  for  the  slight  local  trouble,  perfectly  well, 
yet  on  making  an  examination  you  find  the  disease  advanced 
beyond  all  possibility  of  doing  any  good. 

An  elderly  Scotch  gentleman  was  sent  to  me  by  Dr. 
Nisbett,  of  Gravesend.  To  all  appearance  he  was  the  wiry, 
healthy-looking  Scot.  "  Hard  as  nails,"  he  said  he  was,  but 
he  was  a  little  troubled  by  irregular  action  of  the  bowels; 
sometimes  costive,sometimes  loose;  and  he  occasionally  passed 
a  little  blo&d.  On  examination  I  found  what  I  really  did 
not  expect,  a  hard,  scirrhous  mass  in  the  rectum  extending 
higher  up  the  bowel  than  I  could  reach.  By  sheer  power  of 
constitution  he  lived  a  little  more  than  twelve  months  from 
that  interview. 

In  October,  1878,  Mr.  Wilton,  of  Sutton,  sent  a  gentle- 
man, aet.  34,  to  me.  He  was  suffering  from  some  pain  in  the 
back,  with  a  weary  sensation  after  exertion;  had  small  losses 
of  blood  at  stool  and  rather  frequent  motions^  always  in  the 
morning  and  sometimes  at  night.  His  idea  was  that  he  had 
piles.  On  examination  I  found  an  epithelioma  commencing 
just  within  reach  of  the  finger,  and  extending,  as  I  found  by 
careful  sounding,  at  least  two  inches  higher  up.  The  growth 
was  causing  some  contraction  of  the  bowel.  This  patient 
was  afterwards  the  subject  of  secondary  deposits  in  the  liver. 
He  died  in  October,  1881. 

When  cancer  attacks  the  uppermost  portion  of  the  rectum 
or  the  sigmoid  flexure,  the  disease  generally  runs  a  more 
rapid  course,  and  isjnuch  more  dangerous;  indeed,  sudden 
death  is  not  uncommon,  as  total  obstruction  takes  place 
quickly^  and  unless  colotomy  is  promptly  performed  the 
intestine  gives  way  above  the  obstruction,  and  death  ensues. 


206  CANCER    OF    THE    RECTUM. 

I  have  seen  a  good  many  examples  of  this,  and  always  warn 
the  friends  of  what  may  happen.  *  Cancerous  stricture  of 
the  upper  part  of  the  sigmoid  flexure  or  the  descending  colon 
is  not  so  immediately  dangerous,  although  the  obstruction 
may  be  total.  I  saw  with  Mr.  Sutton  Sams,  of  Lee,  an 
elderly  lady,  who  had  total  obstruction  high  up  the  bowel, 
and  yet  lived  for  more  than  eight  weeks.  Another  case  I 
saw  in  consultation  with  Mr.  John  M.  Burton,  also  of  an 
elderly  lady,  who  had  a  similar  obstruction  and  lived  for 
many  wrecks,  though  she  had  constant  vomiting.  Many  cases 
of  this  kind  have  come  under  my  notice,  where  patients 
would  not  submit  to  colotomy.  I  need  not  say  that  their 
suffering  is  very  great,  and  loudly  calls  for  surgical  inter- 
ference. Af  the  same  time  the  difficulty  of  ascertaining  the 
precise  seat  of  the  obstruction,  in  many  instances,  ties  the 
surgeon's  hands. 

I  now  come  to  the  consideration  of  a  very  important  but 
unsatisfactory  part  of  my  subject,  viz.  What  can  one  do 
for  the  relief  of  these  terribly  unfortunate  persons  ? 

1  have  never  seen  any  benefit  result  from  the  application 
of  caustics  to  growths  within  the  bowel,  but  when  a  cancer- 
ous mass  protrudes,  which,  however,  is  a  somewhat  rare 
occurrence,  I  have  relieved  pain  and  got  rid  of  a  good  deal 
of  the  growth  by  using  the  arsenite  of  copper  with  mucilage, 
as  a  paste;  this  destroys  rapidly  without  increasing  the  suf- 
fering at  the  time;  it  does  not  cause  bleeding,  and,  as  far  as 
my  experience  goes,  it  is  free  from  danger. 

The  treatment  in  the  majority  of  cases  of  cancer  still 
resolves  itself,  for  the  most  part,  into  an  attempt  to  assuage 
the  suffering  of  the  patient.  Pain  is  generally  mitigated  by 
the  recumbent  posture,  and  good,  easily  assimilated,  nourish- 
ing diet,  with  alcohol  in  moderate  quantities.  All  varieties 
of  sedatives  may  be  used  with  benefit,  externally  and  inter- 
nally, and  when  one  drug  loses  its  effect  another  should  be 
substituted.  Opium  in  its  several  forms  is  the  most  effective 
agent  we  possess.  It  may  be  used  as  a  suppository  in 
which  case  the  best  formula  is  morphia,  with  glycerine  and 
gelatine  (three  of  glycerine  to  one  of  gelatine),  as  this  melts 
very  soon,  and  does  not  feel  like  a  foreign  body  in  the  sensi- 
tive bowel,   as  suppositories  made  of  cacao  butter  so  fre- 

• 
*  Sir  James  Paget  related  a  case  to  me  where  very  little  was  thought 
to  be  the  matter  with  the  patient  until  nine  days  before  entire  obstruc- 
tion took  place  and  death. 


CANCER   OF    THE    RECTUM.  207 

quently  do;  injections  of  Battley's  sedative,  nepenthe,  or 
black  drop  in  starch,  sometimes  afford  great  relief.  Solid 
opium  by  the  mouth  is  a  great  favorite  with  me,  but  the 
objection  to  it  is  that  the  stomach  gets  irritated,  the  appetite 
fails,  and  the  bowels  are  confined.  Probably  most  patients 
obtain  the  greatest  comfort  from  hypodermic  injections  of 
morphia;  but  no  opiate  can  be  used  lon-g  without  inducing  a 
state  of  mind  almost  as  unendurable  as  the  pain  of  the  dis- 
ease and  therefore  great  care  should  be  taken  to  husband  the 
remedy  as  much  as  possible,  never  using  a  larger  dose  than 
is  absolutely  necessary,  bearing  in  mind  that  you  may  have 
to  rely  upon  it  more  or  less,  even  for  months.  I  have  had 
many  patients  who  from  small  beginnings  got  to  inject  from 
eight  to  fifteen  grains  of  morphia  in  the  twenty-four  hours, 
and  the  condition  of  mind  of  these  patients  was  really  fear- 
ful. Many  persons  who  had  injected  such,  large  doses,  have 
told  me  that  they  preferred  the  most  excruciating  pain  to  the 
mental  distress  the  morphia  produced,  and  have,  even  of 
their  own  accord,  left  off  the  drug  and  endured  the  physical 
suffering. 

It  has  recently  been  asserted  by  Mr.  John  Clay,  of  Birm- 
ingham, that  Chian  turpentine  has  a  curative  action  in  cer- 
tain cases  of  cancer.  Following  Mr.  Clay's  method,  I  have 
administered  this  drug  in  forty-nine  'cases  of  malignant  dis- 
ease of  the  rectum,  many  of  the  patients  taking  it  for  several 
months,  even  up  to  a  short  time  before  death.  The  turpen- 
tine was  genuine,  being  obtained,  for  the  most  part,  from  the 
chemists  recommended  by  Mr.  Clay;  in  only  two  cases  did  I 
see  the  slightest  mitigation  of  symptoms.  Both  these  patients 
took  the  medicine  for  nearly  twelvemonths,  but  the  improve- 
ment was  quite  evanescent,  and  the  patients  died..  In  all 
the  other  cases,  either  no  effect  was  manifested  or  only  a  bad 
one,  viz.,  nausea  and  frequent  derangement  of  the  appetite 
and  functions  of  the  stomach.  The  drug  was  exhibited  in 
the  best  way,  both  in  solution  and  pill,  and  in  many  cases 
combined  with  sulphur.  I  have  seen  several  patients  who 
had  been  under  Mr.  Clay's  treatment,  but  they  were  in  no 
way  benefited  any  more  than  those  treated  by  myself, 
although  one  case  was  considered  by  Mr.  Clay  to  be  doing 
very  well,  and  was  probably  reported  as  cured. 

When  cancerous  growths  approach  the  anus  considerable 
relief  may  be  obtained  by  dividing  the  sphincter  muscles; 
defecation  is  thus  rendered  easier,  and  no  possible  compres- 
sion can  be  exercised.     Usually,  as  I  have  said  when  speak- 


2o8  CANCER    OF    THE    RECTUM. 

ing  of  stricture,  a  cancer  of  the  upper  part  ot  the  rectum 
paralyzes  the  sphincters,  doubtless  from  pressure  on  nerves, 
and  the  patient  is  not  able  to  retain  the  motions,  especially 
if  they  are  at  all  liquid.  When  diminution  of  the  calibre  of 
the  bowel  is  induced  by  cancer  near  the  anus.  Professor 
Verneuil  has  proposed  free  division  of  the  gut  in  the  dorsal 
median  line,  or  even  the  excision  of  a  segment  of  the 
posterior  wall  of  the  rectum.  The  former  operation  I  have 
frequently  practiced;  the  latter  does  not  commend  itself  to 
my  mind. 

In  encephaloid  of  the  rectum  great  temporary  advantage 
and  much  relief  from  pain  may  be  obtained  by  tearing  out 
the  growth  by  the  fingers  or  a  scoop  (as  the  late  Professor 
Simon  advocated  in  cancer  of  the  uterus).  I  prefer  my 
fingers.  You  must  be  bold  in  doing  this,  and  enucleate  the 
whole  growth  quickly  and  resolutely.  If  you  tear  away  only 
superficial  portions,  haemorrhage  may  occur  to  a  considera- 
ble extent,  which  must  exhaust  your  patient,  and  no  real 
benefit  will  accrue. 

I  had  a  case  under  treatment  in  conjunction  with  Mr. 
Pinching,  of  Gravesend,  in  the  person  of  a  member  of  our 
own  profession.  An  immense  encephaloid  growth  almost 
filled  up  his  pelvis,  and  he  came  to  London  to  see  if  I  could 
do  anything  for  him.  He  was  in  such  a  condition  that  I 
thought  he  could  not  bear  colotomy,  but  I  saw  that  if  I  could 
remove  the  growth  in  great  part  without  his  losing  blood  to 
any  extent  great  relief  must  follow.  Accordingly,  assisted 
by  Mr.  Pinching^  I  made  a  free  division  of  the  anus,  the 
muscles  and  fat  around  which  had  been  so  thinned  away  by 
the  pressure  of  the  growth  that  it  was  only  like  cutting 
through  thin,  devitalized  skin.  Only  one  small  vessel 
appeared  inclined  to  bleed,  and  this  I  immediately  twisted. 
I  now  passed  my  hand  gently  into  the  pelvis,  got  I  fingers 
well  above  the  growth,  and  tore  it  out.  A  large  mass  was  at 
once  removed.  I  then  continued  to  remove  all  I  could  find, 
and  it  came  away,  exactly  like  brain  in  appearance,  and  in 
quantity  sufficient  to  fill  a  good-sized  pudding-basin.  I  had 
come  fully  prepared  with  subsulphate  of  iron,  the  actual 
cautery,  sponges,  and  wool,  in  order  to  be  able  to  plug  at 
once  should  haemorrhage  take  place,  but  to  my  astonishment 
there  was  no  bleeding  worth  mentioning,  and  the  cavity  from 
which  the  cancer  had  been  removed  was  dry  and  gray  in 
color,  with  red  spots.  As  a  precaution  against  secondary 
haemorrhage  I  put  in  sponges  powdered  with  the  subsulphate 


CANCER    OF    THE    RECTUM.  209 

of  iron,  but  there  was  no  bleeding  at  all.  From  the  day  after 
the  operation  the  patient  rallied,  lost  his  night  sweats,  ate 
and  drank  all  we  gave  him,  and  was  able  to  return  home  in 
a  few  weeks.  After  this  he  lived  in  comparative  comfort  for 
two  months,  then,  as  the  growth  returned,  he  very  gradually 
died  from  exhaustion,  nearly  five  months  having  elapsed  since 
he  underwent  my  treatment.  Twice  since  this  I  have  carried 
out  this  plan  in  a  similar  manner,  and  in  both  cases  great, 
though  temporary,  relief  followed.  I  do  not  see  why  it 
should  not  be  adopted  in  some  cases  of  epithelioma.  I  was 
surprised  to  observe,  in  the  three  cases  after  the  removal  of 
the  cancerous  growths,  that  the  facial  appearance  of  the 
patients  so  immensely  improved;  in  fact,  they  all  lost  the 
malignant  aspect,  and  not  until  the  growth  gradually 
returned,  and  with  it  the  poisoning  of  their  blood  and  tissues, 
did  the  countenance  reassume  its  worn,  haggard  look.  So, 
also^  in  respect  to  strength,  freedom  from  pain,  appetite,  and 
capacity  for  sleep,  the  change  for  the  better  was  remarkable. 
In  this  variety  of  cancer,  though  colotomy  would  afford  in 
some  degree  relief  from  pain,  inasmuch  as  the  abundant 
cancer  elements  are  still  present,  poisoning  of  the  general 
system  would  continue  in  full  force,  and  thus  extension  of 
the  term  of  life  is  not  to  be  obtained,  and,  indeed,  can  hardly 
be  anticipated;  in  such  cases,  where  I  have  performed 
colotomy,  I  have  found  the  patients  have  rapidly  succumbed. 

Two  operations  have  been  practiced  for  the  relief  of  rec- 
tal cancer.  The  one  is  extirpation  of  all  the  diseased  por- 
tions of  the  rectum,  which,  further,  is  stated  by  some  surgeons 
to  effect  a  positive  cure  of  the  disease  in  some  cases.  The 
other  operation  is  colotomy,  lumbar  or  inguinal,  which  only 
professes  to  relieve  pain,  and  possibly  extend  the  term  of 
the  patient's  life. 

Extirpation  of  the  rectum  (as  it  is  frequently  termed), 
broadly  speaking,  may  be  undertaken  in  any  form  of  cancer 
which  does  not  necessitate  the  removal  of  more  than  four 
and  three  quarters  or  five  inches  of  the  rectum  in  the  male 
and  about  one  inch  less  in  the  female.  Subject  to  the  results 
of  increased  experience,  I  should  also  say  that  if  great 
adhesions  are  formed  to  the  sacrum  or  to  the  base  of  the 
bladder  and  prostate  gland,  or  to  the  neck  of  the  uterus  in 
women,  the  operation  is  probably  not  admissible,  and  cer- 
tainly not  desirable.  Again^  if  any  enlarged  glands  exist  in 
the  inguinal  or  lumbar  regions,  the  operation  cannot  be 
recommended;  lastly,  I  should  say  the  patient  ought  not  to 
14 


2IO  CANCER    OF    THE    RECTUM. 

be  SO  exhausted  as  to  render  it  doubtful  whether  the  neces- 
sarily rather  free  loss  of  blood  would,  to  a  great  degree, 
endanger  life.  The  length  of  the  rectum  from  the  anus 
which  may  be  removed  without  opening  the  peritoneal  cavity 
differs  in  individuals,  and  the  conclusions  arrived  at  by 
measurements  of  the  dead  body,  or  by  taking  plaster  casts 
of  the  reflections  of  the  peritoneum,  are  fallacious^  and  must 
be  taken  as  an  approximation  to  the  truth  only.  In  a  female 
patient  on  whom  I  operated,  Douglas'  pouch  was  only  two 
inches  from  the  anus.  In  a  male  fully  five  inches  of  the 
rectum  were  removed,  and  the  peritoneum  never  seen;  and 
in  another  male,  in  which  not  more  than  three  and  a  half 
inches  were  cut  off,  the  peritoneum  was  opened  and  a  coil 
of  intestine  protruded.  A  point  of  considerable  importance 
in  operating  is  to  divide  the  levator  ani  muscle  thoroughly 
and  dissect  it  carefully  upward,  by  which  means  you  get  the 
rectum  to  come  readily  down,  and  in  making  the  necessary 
traction  on  it  you  do  not  draw  the  peritoneum  down  with  it. 
Another  point  worth  remembering  is  that  the  meso-rectum 
is  more  developed  in  some  subjects  than  in  others,  and 
descends  below  the  upper  half  of  the  rectum.  Care  must  be 
taken  in  using  the  knife  close  to  the  sacrum,  as  you  may 
easily  divide  the  trunk  of  the  middle  hsemorrhoidal  artery, 
when  severe  bleeding  will  take  place,  and  difficulty  may  be 
experienced  in  arresting  it.  This  accident  has  occurred  to 
me,  but  I  was  able  to  sieze  the  vessel  and  secure  it  quickly. 
From  the  full  and  sudden  rush  of  blood,  however,  I  felt  con- 
vinced that  a  weak  patient  might  readily  die  on  the  table. 
It  is  not  my  intention  to  enter  into  the  history  of  the  opera- 
tion of  excision  of  the  rectum,  nor  shall  I  describe  the 
various  ways  in  which  it  may  be  performed;  but  I  beg  to 
refer  the  reader  who  wishes  the  fullest  information  on  these 
subjects  to  the  able  and  exhaustive  work  of  Dr.  Marchand, 
entitled  "  Etude  sur  I'extirpation  de  I'extremite  inferieure 
du  Rectum."  I  will  only  here  mention  that  Paget,  in  the 
year  1739,  excised  the  rectum  for  cancer;  that  after  this  the 
operation  remained  in  abeyance  until  1828,  when  it  was 
revived  by  Lisfranc,  who  performed  it  in  several  cases  with 
success.  At  a  comparatively  recent  date  it  has  been  fre- 
quently undertaken  by  both  French  and  German  surgeons, 
and  with  such  good  results  as  to  establish  the  operation  on 
a  reliable  basis.  The  Americans  and  ourselves  have  brought 
up  the  rear;  possibly  we  are  more  cautious  and  have  had 
our  doubts  as  to  the  great  benefits  claimed  for  it  by  our 


CANCER   OF    THE    RECTUM.  211 

foreign  confrlres ;  certainly  we  are  justified  in  distrusting 
such  statements  as  Dieffenbach's,  who  says  that  he  had  had 
thirty  cases  of  successful  extirpation  of  the  rectum,  the 
patients  living  many  years  after  the  operation.  We  have 
also  felt  incredulous  as  to  the  advantage  derived  from  cutting 
out  the  rectum,  a  portion  of  the  urethra,  prostate  gland,  and 
base  of  the  bladder,  as  did  Nussbaum,  who  gravely  assures 
us  that  the  patient  recovered  all  his  functions  and  lived  for 
three  years. 

My  own  experience  of  removing  cancerous  growths  from 
the  rectum  is  not  great.  I  find  that  I  have  excised  segments 
of  the  bowel  by  knife  alone,  or  combined  with  the  ecraseur  or 
ligature  (elastic  or  inelastic),  in  thirteen  cases,  and  in  six- 
teen patients  I  have  removed  the  rectum  in  its  whole  cir- 
cumference, the  largest  portions  taken  away  being,  in  two 
cases,  five  inches  and  five  inches  and  a  half  in  length, 
respectively. 

I  shall  not  enlarge  on  my  operations  on  segments  of  the 
rectum,  because  the  question  to  be  determined  is.  Can  one 
cure  a  patient  who  has  cancer — say  epithelioma — by  excising 
the  whole  of  the  diseased  portion  of  the  rectum  ? 

Speaking  generally  of  partial  removals  of  the  circumfer- 
ence of  the  bowel,  I  must  say  I  consider  the  operation  unsat- 
isfactory. In  all  my  cases  which  I  had  the  opportunity  of 
observing  for  about  a  year,  either  a  return  of  the  disease 
took  place  in  t]je  rectum,  or  the  glands  in  the  groin  became 
affected,  or  there  ensued  disease,  probably  cancer,  in 
some  internal  organ,  mostly  the  liver.  I  find  seven  out  of 
thirteen  cases  died  within  eleven  months  of  the  operation, 
and  in  three  there  was  a  return  of  the  growth  in  the  rectum. 
This  may,  of  course,  be  attributed,  and  I  think  rightly,  to 
my  not  having  totally  extirpated  the  local  disease;  but  in  four 
cases  the  disease  did  not  return  in  the  bowel,  but  in  the 
glands.  One  of  my  patients  died  suddenly,  two  days  after 
the  operation,  from  syncope  on  getting  out  of  bed.  Another 
died  on  the  fourteenth  day,  from  erysipelas.  The  four 
remaining  cases  recovered  from  the  operation,  but  I  have  no 
knowledge  of  the  ultimate  result.  In  one  case,  a  patient  of 
Mr,  George  Ord,  the  growth  did  not  return  until  after  one 
year  and  five  months  had  elapsed.  I  had,  therefore,  arrived 
at  the  conclusion  that  partial  removal  of  the  rectum  was  an 
operation  which  could  not  be  very  strongly  recommended. 
Another  objectionable  feature  in  my  case  was  that,  contrary 
to  the  experience  of  some  of  my  professional  brethren,  the 


212  CANCER    OF    THE    RECTUM. 

patients  had  incontinence  of  faeces  when  a  large  portion  of 
the  sphincters  was  removed  All  my  cases  were  not  epith- 
elioma; some  presented  scirrhous  nodules,  as  in  the  case  I 
mentioned,  where  the  growth  was  situated  over  the  prostrate 
gland. 

Case  i. — My  first  excision  of  the  whole  circumference  of 
the  rectum  was  performed  at  St.  Mark's  Hospital  on  the  2d 
of  March,  1874.  The  patient  was  a  woman,  forty-seven  years 
old,  who  was  sent  to  me  by  Dr.  Thomas.  She  was  a  widow, 
with  a  family;  she  did  not  look  very  unhealthy,  and  was 
fairly  nourished,  but  she  said  she  had  become  thinner.  Six 
months  back  she  had  been  operated  on  in  the  London  Hos- 
pital, for  fissure,  but  she  did  not  get  well;  soon  after  the 
operation  the  pain  was  as  bad  as  before  it.  There  was  con- 
stant gnawing  pain  in  the  anus,  much  increased  on  defeca- 
tion, and  she  was  obliged  to  strain  at  stool.  Exa77iination. — 
The  anus  was  patulous,  but  just  inside  was  a  contraction 
formed  by  hardish,  ulcerated  growths,  which  nearly  encircled 
the  bowel.  The  extent  upward  w^as  not  more  than  an  inch. 
There  was  no  history  of  syphilis  nor  any  symptom.  I  had 
no  hesitation  in  pronouncing  the  disease  to  be  epithelioma, 
and  I  removed  it  by  a  circular  incision  around  the  anus 
including  the  sphincter.  I  dissected  the  bowel  up  without 
difficulty,  as  there  was  no  adhesions,  drew  the  gut  outside, 
and  cut  it  off  with  scissors.  I  took  care  to  have  the  bowel 
held  well  out  with  a  volsellum.  There  was  smart  bleeding, 
but  four  vessels  being  tied,  it  all  ceased.  I  then  joined  the 
stump  of  the  rectum  to  the  skin  with  six  wire  sutures.  On 
the  day  after  the  operation  there  was  much  swelling,  and  on 
the  day  following  there  was  lividity  of  the  skin  and  great  ten- 
sion, so  I  was  compelled  to  remove  all  the  sutures,  and  a 
quantity  of  pus  was  discharged  and  the  parts  widely  gaped. 
I  ordered  charcoal  poultices  and  injections  of  Condy's  fluid. 
After  a  few  days  the  wound  assumed  a  healthy  appearance, 
and  the  patient  made  good  recovery.  I  was  much  astonished 
at  the  way  in  which  the  rectum  gradually  grew  downward 
and  joined  the  skin,  forming  an  excellent  cicatrix.  Before 
leaving  the  hospital  she  had  some  power  over  her  motions,  I 
watched  this  patient  for  sixteen  months,  following  her  to  a 
distance  rather  than  lose  sight  of  her.  No  disease  returned 
in  the  rectum,  but  in  eleven  months  she  had  abdominal 
sysptoms;  emaciation  was  very  rapid;  she  suffered  much, 
and  died  sixteen  months  after  the  operation,  having  kept  her 
bed  for  five  months. 


CANCER    OF    THE    RECTUM.  213 

Case  2. — A  man,  aet.  36,  was  taken  into  St.  Mark  s  Hospi- 
tal, and  operated  upon  by  me  on  the  26th  of  October,  1874. 
He  had  suffered  from  haemorrhoids,  and  had  been  under  my 
care  fifteem  months  before.  He  continued  well  until  three 
months  ago,  when  he  began  to  suffer  pain  in  the  rectum,  and 
passed  blood  and  mucus;  the  bowels  were  almost  always 
relaxed,  and  he  had  but  little  straining,  but  he  had  inconti- 
nence of  faeces.  The  patient  was  unhealthy  looking,  and 
had  lost  flesh  and  strength.  On  examination  a  cancerous 
growth  was  found  encircling  three-fourths  of  the  rectum  on 
its  dorsal  surface;  the  anterior  portion  seemed  uninvaded, 
nevertheless,  I  thought  it  advisable  to  remove  the  gut  in  its 
entire  circumference,  by  an  elliptical  incision.  A  silver 
catheter  was  passed  into  the  bladder,  to  steady  the  urethra. 
The  part  removed  was  about  two  inches  in  length;  no  diffi- 
culty presented  itself  in  the  operation.  .  I  did  not  put  in  any 
sutures,  but  filled  the  wound  with  wool  soaked  in  carbolized 
oil.  No  bad  symptoms  followed,  and  the  parts  were  quite 
healed  in  four  weeks.  The  patient  returned  to  me  three 
months  after  the  operation,  with  contraction  of  the  anal  ori- 
fice. I  made  an  incision  to  correct  this,  and  he  had  no  trou- 
ble afterwards.  Seven  months  subsequent  to  the  operation 
the  cancer  appeared  higher  up  the  rectum;  he  refused  any 
further  surgical  interferance.  After  a  little  time  I  lost  sight 
of  him,  and  therefore  do  not  know  how  long  he  survived. 
For  four  months  after  the  operation  he  was  quite  comfortable, 
had  no  incontinence  of  faeces,  and  was  able  to  do  his  work. 

Case  3. — A  man,  in  rather  poor  circumstances,  but  who 
would  not  come  into  the  hospital,  was  sent  to  me  by  Mr. 
Slater,  of  Canonbury.  I  saw  him  first  in  January  of  1875. 
He  was  a  spare  man,  about  fifty.  He  had  suffered  pain  for 
some  months,  in  the  bowel;  it  was  pretty  constant  and  much 
aggravated  on  action  of  the  bowels.  He  felt  weak  and  had 
lost  much  weight.  On  examination  I  found  a  rather  large, 
cancerous  growth,  two  inches  from  the  annus;  it  did  not 
involve  the  whole  circumference  of  the  bowel;  it  was  mov- 
able in  all  directions.  I  could  easily  reach  its  upper  border, 
and  bring  the  growth  close  to  the  anus.  I  proposed  remov- 
ing it,  but  the  man  declined.  In  March  following  he  came 
to  me  again,  saying  he  had  suffered  so  much  that  I  might  do 
what  I  liked  to  afford  him  relief.  Examination  showed  that 
the  cancer  had  approached  much  nearer  to  the  anus,  but 
there  still  remained  a  zone  of  healthy  mucous  membrane 
between  the  growth  (which  I  believed  to  be  epithelial)  and 


214  CANCER    OF    THE    RECTUM. 

the  anus.  There  did  not  appear  to  be  any  important  adhe- 
sions except  dorsally;  anteriorly  very  little  amiss  was 
detected,  and  the  gut  was  quite  movable.  I  determined  on 
excising  the  growth,  and  to  leave  the  external  sphincter  by 
carrying  my  knife  around  the  bowel  in  the  space  between  the 
two  muscles.  I  discovered  when  I  made  the  incision,  from 
which  blood  flowed  plentifully,  that  I  could  not  safely 
remove  the  growth,  so  I  made  a  deep  dorsal  cut  in  the 
median  line,  nearly  to  the  coccyx.  I  was  delighted  to  find 
the  amount  of  room  this  gave  me,  and  how  it  rendered  the 
operation  comparatively  easy.  In  all  my  subsequent  cases 
I  have  commenced  my  operation  by  cutting  from  the  point 
of  the  coccyx  well  up  into  the  bowel,  a  proceeding  so 
strongly  recommended  by  Prof-  Verneuil.  No  serious  obsta- 
cles were  found,  and  I  ablated  about  three  inches  of  the  rec- 
tum, cutting  well  free  of  the  growth.  I  attempted  to  bring 
the  stump  of  the  rectum  to  the  skin  by  sutures,  as  I  hoped 
thus  to  save  the  external  sphincter,  which  I  had  preserved, 
but  the  tension  was  too  great,  and  I  therefore  only  filled  the 
wound  with  sponges  soaked  in  a  weak  solution  of  chloride  of 
zinc.  The  after  progress,  on  the  whole  was  satisfactory  but 
slow,  and  the  wound  took  seven  weeks  in  healing.  This 
patient  died  fourteen  months  after  the  operation.  He  was 
in  comparative  comfort  for  twelve  months,  and  had  fair 
command  over  his  motions,  unless  they  were  liquid.  The 
disease  did  not  return  in  the  rectum,  but  the  glands  in  the 
groin  became  affected,  and  possibly  also  some  internal 
organs.     He  suffered  much  pain  toward  the  last. 

Case  4. — A  gentleman,  set.  60,  came  to  me  from  the  coun- 
try saying  he  was  suffering  from  stricture  of  the  rectum, 
which  had  troubled  him  for  about  eight  or  nine  month  ;  he 
had  consulted  several  eminent  provincial  surgeons,  and  had 
used  bougies  with  temporary  benefit.  He  was  thin,  but  fairly 
strong  and  active;  the  expression  of  his  face  was  healthy. 
On  examination  I  found  his  bowel  obstructed  by  a  growth 
which  quite  surrounded  the  gut;  it  was  ulcerated  in  parts;  it 
commenced  about  an  inch  from  the  anus,  and  the  zone  meas- 
ured about  two  inches  at  most  in  length;  it  was  freely  mov- 
able in  all  directions;  no  glandular  complications  could  be 
detected.  I  advised  its  immediate  removal.  He  went  home 
to  consider  the  matter,  to  consult  his  relatives,  and  one  of 
the  surgeons  he  had  seen.  He  returned  to  town  in  a  few 
weeks  and  I  operated  upon  him  on  the  26th.  of  January, 
1876.     I  operated  exactly  as  in  the  last  case,  save  that  I 


CANCER    OF    THE    RECTUM.  215 

made  the  dorsal  incision  the  preliminary  step.  In  this  case 
the  bleeding  was  very  free,  and  I  liberally  used  the  actual 
cautery  to  the  cut  surface  of  the  rectum  as  well  as  to  other 
parts.  The  wound  was  filled  with  sponges  steeped  in  a 
weak  solution  of  carbolic  acid,  and  I  introduced  a  tube  into 
the  rectum  in  order  that  wind  might  escape,  the  retention  of 
which  had  much  troubled  my  last  patient.  The  wound 
healed  kindly.  There  was  no  fever  after  the  first  forty-eight 
hours,  and  the  patient  suffered  remarkably  little.  In 
five  weeks  he  went  away  quite  satisfied  and  I  expected  a 
good  result;  but  I  was  disappointed,  as  in  five  months  he 
came  to  me  with  a  return  of  the  growth,  quite  near  the  anus, 
involving  the  scar  and  the  skin;  it  was  a  hard  lump,  the  size 
of  half  a  walnut,  and  I  advised  him  to  let  me  cut  it  out;  he 
acquiesced,  and  I  removed  it  freely,  but  did  not  take  away 
the  w^hole  circumference  of  the  gut.  This  I  afterwards 
regretted,  as  I  saw  him  in  about  three  months  again  with 
much  more  growth  at  the  anterior  part  of  the  rectum.  He 
was  now  now  weak  and  greatly  broken  in  health,  and  despair- 
ing of  relief  he  refused  any  more  active  treatment.  I  heard, 
from  his  friends,  that  he  died  just  eleven  months  and  a  half 
from  the  first  operation. 

Case  5. — I  saw  with  the  late  Dr.  Daldy  a  single  lady,  set. 
40,  who  was  affected  with  what  she  supposed  to  be  piles. 
She  lost  blood  in  small  quantities,  had  frequent  diarrhoea 
with  incontinence  of  faeces,  and  there  was  a  discharge  of 
sanious,  ill-smelling  mucus.  The  pain  was  not  great,  except 
when  the  bowels  acted.  She  was  fairly  nourished,  and  was 
going  about  her  duties  as  usual.  On  examination  I  found  a 
growth  in  the  rectum,  one  and  a  half  inches  from  the  anus, 
and  extending  but  Uttle  upward  ;  it  was  hard  and  rough  to 
the  touch  in  some  parts  and  pulpy  in  others  ;  it  was  situated 
principally  on  the  anterior  part  of  the  bowel,  but  extended 
laterally  nearly  to  the  sacrum  ;  it  was  most  adherent  to  the 
vaginal  wall,  and  could  be  felt  distinctly  with  the  finger  in 
the  vagina,  but  I  thought  it  did  not  involve  the  vaginal 
mucous  membrane.  With  some  misgiving  I  advised 
the  removal  of  the  growth,  fearing  that  I  should  have  to 
take  out  a  portion  of  the  vagina,  in  order  to  thoroughly 
extirpate  it.  When  "the  patient  found  that  no  other  course 
was  open  to  her  to  obtain  relief,  and  that  the  danger  would 
probably  be  increased  by  delay,  she  consented  to  have  the 
operation  done.  In  order  to  obtain  plenty  of  room  I  com- 
menced  with   the   dorsal   median   incision,    and   made   an 


2l6  CANCER    OF    THE    RECTUM. 

exceedingly  careful  and  cautious  dissection,  but  I  found  the 
growth  so  intimately  connected  with  the  vaginal  wall  that  I 
was  compelled  to  remove  a  portion  of  the  vagina,  fully  one 
inch  in  length  by  half  an  inch  in  breadth,  the  hole  made  being 
elliptical.  After  having  removed  all  the  diseased  tissues,  I 
brought  the  edges  of  the  wound  together  with  four  iron 
sutures.  I  put  no  dressing  in  the  wound,  simply  placing  a 
tube  in  the  bowel.  On  examining  the  growth  there  could 
be  no  doubt  that  it  was  mainly  epithelial,  but  there  was 
much  warty  structure  in  it,  which  accounted  for  the  rough- 
uess  I  had  detected.  Fortunately  the  wound  in  the  vagina 
healed  at  once,  and  the  patient  made  an  excellent  recovery. 
This  lady  I  have  heard  from  recently,  and  she  continues 
quite  well  (three  years  after  the  operation).  This  is  the  best 
result  I  have  as  yet  obtained,  but  it  is  clear  that  the  growth 
was  only  feebly  malignant. 

Case  6. — A  man,  ^t.  6i,  was  admitted  into  St.  Mark's 
Hospital  February,  1877,  suffering  from  epithelioma  of  the 
rectum.  The  disease  had  existed  about  three  months. 
There  was  slight  obstruction  of  the  bowel,  and  he  had  great 
pain  ;  he  had  straining  at  stool,  and  there  was  a  constant 
bloody  mucous  discharge  ;  he  had  no  incontinence  of  faeces 
unless  they  were  liquid  ;  he  was  a  small,  spare  man,  of  not 
unhealthy  appearance  ;  he  did  not  think  he  had  lost  flesh,  as 
he  was  always  thin  ;  he  had  always  enjoyed  good  health. 
On  examination  a  hard  growth  was  found,  commencing  an 
inch  from  the  anus  ;  it  encircled  the  bowel,  save  on  the  left 
side,  which  was  soft  and  ulcerated  ;  it  extended  about  two 
inches  upward  ;  it  was  fairly  moveable,  except  toward  the 
prostate.  I  operated  in  the  usual  manner,  save  that  I  used 
the  Paquelin  cautery  more  freely  than  in  some  cases,  and  I 
severed  with  the  Paquelin,  inserting  a  plug  into  the  bowel  to 
cut  upon.  The  gut  was  very  adherent  to  the  prostate  gland, 
and  took  a  considerable  time  to  dissect  off ;  the  capsule  of  the 
prostate  was  removed,  and  the  vesiculae  seminales  plainly  seen. 
Rather  more  than  three  and  a  half  inches  were  removed.  I 
saved  the  internal  sphincter  muscle.  The  peritoneum  on 
the  right  side  of  the  bowel  was  opened,  and  I  saw  a  coil  of 
intestine.  A  sponge,  well  carbolized,  was  placed  against  the 
opening,  and  the  wound  was  filled  withVool  well  soaked  in 
carbolic  oil.  After  the  operation  the  patient  had  not  a  bad 
symptom,  and  he  left  the  hospital  quite  well,  having  gained 
flesh  and  improved  in  appearance.  This  patient  died  thirteen 
months  after  the  operation.     No  return   of  the  disease  took 


CANCER    OF    THE    RECTUM. 


217 


place  in  the  rectum,  but  the  glands  in  the  inguinal  regions 
were  enormously  enlarged,  and  one  gland  was  the  seat  of 
fungoid  ulceration. 

Case  7. — A  man,  aet.  50,  was  taken  into  St.  Mark's  Hospital 
in  March  of  1878,  and  came  under  my  care.  He  was  a  tall, 
thin  man,  with  somewhat  haggard  countenance,  but  he  was 
not  weak,  and  had  worked  as  a  carpenter  up  to  his  admis- 
sion. He  had  suffered  for  some  months,  he  could  not  say 
exactly  how  many,  from  trouble  in  the  bowel,  the  common 
symptoms  of  ulceration  or  malignant  disease  being  present. 
On  examination  I  detected  an  epithelial  growth  in  the 
rectum,  commencing  within  an  inch  and  a  half  of  the  anus, 
and  passing  up  so  high  that  I  could  only,  by  making  the 
patient  stand  up  and  strain  down,  just  feel  the  upper  border 
of  the  cancer,  and  satisfy  myself  that  I  could  remove  the 
whole  of  the  disease.  The  growth  was  more  than  commonly 
adherent,  especially  to  the  left  side.  A  silver  catheter  was 
passed  into  the  bladder  when  I  reached  the  anterior  part  of 
the  rectum.  I  made  the  dorsal  incision,  and  carried  my 
knife  around  in  the  interspace  between  the  sphincter  muscles. 
The  dissection  was  very  difficult  anteriorly  and  on  the  left 
side,  and  I  had  to  go  very  deeply  to  get  all  the  growth  away. 
I  made  use  of  my  fingers  and  avoided  the  knife  as  much  as 
I  could.  The  haemorrhage  was  free  throughout,  but  con- 
trollable by  pressure.  Indeed  not  a  single  vessel  required 
ligature  ;  a  few  were  twisted.  In  separating  the  diseased 
portion  of  gut  anteriorly  the  prostate  gland  and  the  vesiculae 
seminales  were  fully  exposed.  The  stump  of  the  rectum 
could  not  have  been  brought  down  to  join  the  skin  if  I  had 
desired  to  bring  these  parts  together.  For  a  few  days  the 
patient  was  in 'a  critical  condition,  the  temperature  keeping  at 
104°  and  a  little  above,  but  these  symptoms  passed  off  with 
the  establishment  of  suppuration  and  the  separation  of  some 
largish  sloughs,  and  he  made  a  good  though  rather  slow 
recovery.  He  left  the  hospital  quite  well,  with  the  gut  grown 
down  to  the  skin,  and  the  whole  part  as  smooth  and  soft  as 
healthy  mucous  membrane  could  be.  Eight  months  after 
the  operation  the  man  had  such  a  contracted  orifice  to  the 
bowel  that  I  was  compelled  to  take  him  into  the  hospital, 
and  finding  that  bougies  were  of  no  avail,  to  divide  the  anus 
on  both  sides.  This  soon  cured  the  contraction,  but  I  sent 
him  out  with  a  tube,  to  prevent  any  recurrence  of  the  trouble  ; 
this,  however,  failed.  He  still  lives — more  than  three  years 
after  the  operation. 


2i8  CANCER    OF    THE    RECTUM. 

Case  8. — A  gentleman,  aet.  about  60,  was  sent  to  me  by 
Dr.  Wm.  Ord,  in  October,  1876.     He  had  a  nodule  of  hard 
cancer  in  the  cellular  tissue  just  inside  the  anus.     It  was  so 
moveable   and    circumscribed  that  I  could   not    resist  the 
temptation  to   remove    it  by  a  very  free    incision   without 
cutting  out  the  whole  circumference  of  the  bowel.     I  was 
confident  I  had  got  away  all  the  diseased  tissue  recognizable 
by  the  eye  or  touch.      A  microscopic  examination  showed 
the  tumor  to  be  scirrhous.     From   time  to  time  I  saw  this 
gentleman,    and   he   had    no    return    of  the    disease    until 
the  middle  of  March,  when  he  complained  of  discomfort  and 
some  pain  in  the  bowel.     He  had  been   quite  well  for  one 
year  and  five  months.      On  my  examining  him  I  detected 
small  nodules  in  the  mucous  membrane,  about  two  inches 
from  the  anus.      The   site   of  the   old  excision   was   quite 
healthy.     I  urged  him  to  allow  me  to   remove  the  nodules 
at  once,  but  he  consulted  some  other  surgeons,  and  as  they 
told  him  nothing  could  be  done,  as  the  places  were  too  high 
up,  he  declined  to  allow  me  to  interfere.      Some  months 
elapsed  before  this  patient  came  to  me  again  ;  finding  himself 
getting  daily  worse  and  losing  strength  and  flesh,  he  said  he 
was  prepared  to  submit  himself  to  my  wish,  but  on  examining 
him  I  found  the  disease  had  grown  down  nearly  to  the  anus, 
and  was  almost  all  round  the  bowel.     Under  these  circum- 
stances I  said  that  Sir  James  Paget  should  decide  whether 
an  operation  should  be  done  or  not,  and  as  Sir  James  decided 
in  favor  af  an  operation,  I  performed  it  in  August,  removing 
fully  four  inches  of  the  rectum.     The  growth  was  now  clearly 
epithelial,  in  fact,  was  an  admirable  specimen,  as  was  the 
first  tumor  I  removed  a  typical  example  of  scirrhus.     The 
operation,  in  consequence  of  the  adhesions,  was  a  lengthy 
one,  and  the  bleedinp^  very  severe,  so  much  so  that  I  used  the 
Paquelin  cautery  than  I  had  done  before.     The  peritoneum 
was  not  injured.      A  very  large  chasm  was  left,  and  was 
filled  with  sponges  soaked  in  a  solution  of  salicylic   acid. 
Some  pressure  was  required  to  arrest  a  general  oozing  from 
the  large  surface.      A  tube  was  put  into  the  bowel.     The 
night  following  the  operation  the  patient  had  a  most  severe 
rigor,  and  the   temperature  went  up  to   104.5°.     ^  thought 
something  serious  was  about  to  happen.     I  took  out  all  the 
sponges  and  syringed  the  parts  well  with  solution  of  salicylic 
acid,  and   administered   a  large  dose  of  quinine.      In  the 
morning  the  patient  was  quite  comfortable,  with  the  tempera- 
ture fallen  to  99.5°.     After  this^  although  the  patient  was 


CANCER    OF    THE    RECTUM.  219 

troubled  very  much  by  two  or  three  actions  of  the  bowels 
daily,  which  we  could  not  stop,  he  made  the  most  remarkable 
recovery  I  ever  saw.  Was  able  to  return  into  the  country 
fourteen  days  after  the  operation,  and  in  less  than  four  weeks 
the  whole  chasm  was  filled,  and  the  bowel  grown  quite  down 
to  the  orifice.  All  that  was  done  to  this  patient  was  to  wash 
out  the  wound  by  means  of  a  syringe,  after  the  action  of  the 
bowels.  The  parts  could  not  be  kept  sweet  or  clean,  as  a 
perpetual  oozing  of  faeces  was  taking  place.  This  is  only 
one  example  out  of  hundreds  I  have  had  that  satisfy  me 
that  as  long  as  putrid,  filthy  matter  are  not  retained,  shut  up, 
in  a  wound,  it  will  heal  well  and  rapidly,  indeed,  quite  as 
well  as  if  all  the  antiseptic  treatment  in  the  world  had  been 
adopted.  In  January,  1879,  I  found  this  patient  had  some 
contraction  of  the  anal  orifice  ;  as  bougies  did  not  seem  to 
keep  it  well  open  I  divided  one  side  of  the  orifice  with  a 
knife,  and  by  keeping  a  tube  in  for  a  few  days  all  got  well. 
Curious  to  relate,  though  some  of  the  rectum  was  taken 
away,  it  grew  down,  and  a  portion  of  mucous  membrane 
protruded  from  the  anus  ;  I  thought  of  removing  it,  but  as 
it  seemed  to  be  of  no  consequence  I  did  no  do  so.  This 
patient  died  in  July,  1879 — having  lived  nearly  three  years. 

Case  9. — In  December,  1878,  an  unmarried  lady,  set,  38, 
came  to  me  from  the  country.  She  looked  healthy  and 
cheerful,  but  when  her  face  was  in  repose  there  was  a  sal- 
lowness  not  observable  when  she  was  excited,,  and  also  an 
anxious,  worn  expression.  She  at  once  told  me,  in  the  most 
matter  of  fact  way,  that  she  had  cancer  of  the  rectum,  that 
she  had  consulted  an  eminent  physician  in  the  country,  and 
a  still  more  eminent  surgeon  in  London,  and  they  told  her 
there  was  nothing  for  her  but  to  endure  and,  die.  Her 
friends  confirmed  her  statement.  The  patient  went  on  to 
say  that  for  six  months  her  suffering  had  been  very  great. 
She  had  almost  constant  pain  at  the  bottom  of  the  back,  of 
a  wearing,  sickening  character,  and  the  paroxysms  at  and 
after  a  defecation  were  almost  more  than  she  could  bear. 
She  had  fought  against  this  and  concealed  it  as  much  as 
possible  from  her  friends,  but  her  life  was  really  unendurable. 
On  making  an  examination  an  epithelial  growth  in  the 
rectum  was  patent  enough.  It  commenced  about  an  inch 
and  a  half  from  the  anus,  the  mucous  membrane  nearer  the 
anus  being  quite  healthy.  There  was  no  affection  whatever 
of  the  external  parts.  The  zone  of  epithelial  growth  was 
about  an  inch  in  width,  and  it  involved  nearly  the    whole 


220  CANCER    OF    THE    RECtUM. 

circumference  of  the  bowel.  My  finger  easily  reached 
healthy  bowel  above  the  growth.  There  were  no  enlarged 
glands.  The  growth  was  readily  movable  in  all  directions 
except  on  the  right  side  of  the  vagina,  but  I  did  not  think 
this  would.render  an  operation  more  than  ordinarily  difficult; 
indeed,  taking  the  whole  case  into  consideration,  I  felt  that  it 
was  favorable  for  surgical  interference.  I  expressed  this 
opinion  to  the  patient,  at  the  same  time  guarding 'against  a 
too  sanguine  view  of  the  case.  I  recommended  that  the 
opinion  of  some  eminent  authority  should  be  taken  wi-thout 
the  patient  saying  whom  she  had  previously  seen.  The 
gentleman  she  consulted  endorsed  my  opinion.  When, 
therefore,  proper  arrangements  had  been  made,  special  care 
being  taken  that  my  excitable  patient  should  have  nothing 
to  worry  her  I  performed  the  operation.  The  adhesions 
were  more  than  I  expected,  and  in  dissecting  away  the 
growth  from  the  right  side  of  the  vagina  the  peritoneum  in 
Douglas'  space  was  opened,  and  a  coil  of  intestine  was  seen. 
A  carbolized  sponge  was  immediately  placed  against  the 
opening.  There  was  very  moderate  bleeding.  I  used 
Paquelin's  cautery  to  separate  the  diseased  portion  of  the 
rectum,  where  I  found  some  large  vessels  existed,  the  rest  I 
cut  with  scissors.  The  operation  took  just  forty-five 
minutes  in  its  performance.  The  ether  had  been  stopped, 
and  the  patient  gave  evidence  of  recovery  from  the  anaesthe- 
tic by  moving,  but  when  placed  in  bed  she  was  found  to  be 
still  insensible.  After  a  very  few  minutes  the  nurse,  who 
was  sitting  by  her,  called  my  attention  to  her  appearance, 
and  I  saw  that  she  was  very  pale  and  slightly  blue  in  the  face. 
The  breathing  had  ceased,  and  her  pulse  could  not  be  felt. 
Her  head  was  lowered  and  artificial  respiration  was  com- 
menced by  my  friend,  the  late  Mr.  Carr  Jackson,  and  was 
continued  by  this  gentleman  and  myself  for  two  hours  and  a 
half.  During  this  period  we  several  times  thought  she  was 
dead,  as  immediately  the  artificial  respiration  was  remitted 
no  natural  breathing  took  place,  and  the  heart  ceased  to 
beat.  On  resuming  the  artificial  respiration  the  heart  feebly 
responded,  and  the  face  became  less  deadly  pale.  The 
head  was  all  the  time  kept  low,  and  my  battery  being 
obtained,  we  were  ready  to  use  it  if  required.  Very  gradually 
to  our  great  relief,  natural  breathing  commenced  (though  at 
first  it  was  exceeding  shallow),  and  the  pulse  could  at  times 
be  felt  at  the  wrist.  At  the  end  of  the  anxious  two  and  a 
half*hours  the  breathing  was  fairly  restored,  and  the  heart 


CANCER    OF    THE    RECTUM.  221 

beat  regularly,  though  slowly  and  very  feebly.  At  10.30  the 
the  operation  was  concluded;  at  4.45  she  suddenly  awoke 
to  consciousness,  and  was  able  to  take  some  milk  with  egg 
and  brandy.  After  this  she  rallied,  but  at  1 1  p.  m.  she 
expressed  herself  as  feeling  very  exhausted,  and  was  restless 
and  thirsty.  Her  temperature  was  100.5^,  and  the  pulse 
104.  She  was  quite  warm  all  over,  her  mind  was  perfectly 
clear,  and  she  was  not  in  pain.  She  took  fluid  nourishment 
freely.  On  the  following  morning  I  found  she  had  slept  but 
little  during  the  night,  was  restless,  and  felt  general  malaise 
with  great  thirst.  She  had  passed  a  quantity  of  black  urine, 
like  a  strong  effusion  of  black  tea  ;  the  pulse  was  99,  and 
the  temperature  barely  100^.  She  had  taken  through  the 
night  plenty  of  fluid  nourishment,  Liebig's  cold  soup,  milk, 
with  egg  and  brandy.  There  was  no  sickness,  no  abdominal 
tenderness,  and  she  experienced  but  little  pain  in  the  wound. 
She  was  troubled  with  flatulence,  but  passed  wind  freely 
"from  the  bowel.  I  removed  all  the  sponges  from  the  wound; 
it  looked  healthy  and  quite  sweet.  I  replaced  a  sponge 
which  had  been  steeped  in  a  solution  of  salicylic  acid  against 
the  spot  where  the  peritoneum  had  been  wounded.  She 
was  not  exhausted  after  the  dressing.  During  the  day  she 
improved,  but  at  night  she  was  very  low,  more  restless,  but 
not  in  pain.  She  complained  of  a  tightness  in  the  chest  and 
occasional  spasmodic  pains  in  the  left  side.  Auscultation 
did  not  detect  any  thing  wrong  with  the  lung.  She  was 
still  flatulent,  but  wind  passed  in  both  directions,  and  there 
was  no  distention  of  the  abdomen  nor  tenderness  on  pressure. 
She  had  taken  nourishment  fairly.  There  had  been  no 
vomiting.  The  temperature  w^as  100*^,  and  the  pulse  94.  I 
was  summoned  hastily  at  5  a.m.,  and  found  she  was  dead. 
She  had  taken  some  nourishment  a  few  minutes  before  her 
death;  she  told  the  nurse  she  felt  very  ill,  became  suddenly 
pale,  and  died,  forty-three  hours  after  the  operation.  An 
examination  was  made  eleven  hours  after  death,  by  Mr. 
Jackson  and  myself.  All  the  organs  where  quite  sound.  There 
was  no  pneumonia  nor  pleurisy.  The  heart  was  small,  healthy, 
and  contracted.  There  was  not  a  trace  of  lymph  or  peritoni- 
tis, and  no  fluid  in  the  abdomen.  The  wound  in  Douglas's 
space  was  firmly  united,  and  the  intestine  lying  against  it  was 
not  even  congested.  There  was  one  small  patch  of  conges- 
tion at  the  pyloric  end  of  the  stomach.  I  was  very  anxious 
about  this  patient  from  the  first;  the  syncope  and  coma  were 
grave  matters,  and  she  never  thoroughly  rallied   after  the 


222  CANCER    OF    THE    RECTUM. 

operation,     Syncope,  I  presume,  was  the  immediate  cause  of 
death. 

Case  io. — A  patient,  aet.  52,  was  sent  to  me  at  St.  Mark's 
Hospital,  by  Dr.  Evan  Evans;  he  had  been  more  or  less  ill 
for  fifteen  months,  and  believed  he  had  piles.  He  was  a 
tall,  thin  man,  with  an  unhealthy  looking  face;  he  had  lost 
much  flesh,  and  was  not  very  strong.  I  saw  outside  the  anus 
a  ring  of  tabs  of  skin  discharging  ichorous  matter,  and  inside 
the  anus  several  large  internal  haemorrhoids,  which  were 
very  vascular  and  came  readily  outside  when  he  strained. 
From  the  piles  an  epithelial  growth  extended  up  the  rectum 
for  at  least  three  and  a  half  inches.  It  was  adherent  to  the 
prostate  gland  and  urethra  in  front,  and  on  the  right  side  the 
growth  extended  higher  up  than  on  the  left,  but  I  could 
ascertain  the  whole  extent  of  the  disease,  and  saw  no  insup- 
erable difficulties  to  its  removal.  Accordingly,  on  the  13th 
of  January  I  operated,  cutting  very  wide  of  the  anus  in  order 
to  get  rid  of  the  external  flaps  of  skin,  and  also  to  avoid' 
wounding  the  haemorrhoidal  vessels  which  I  knew  were  large. 
The  dorsal  incision,  owing  to  the  piles,  bled  unusually, 
indeed,  throughout  the  operation  the  bleeding  was  severe.  A 
silver  catheter  passed  into  the  bladder  and  steadied  by  Mr. 
Goodsall,  aided  me  much  in  the  delicate  dissection  of  the 
growth  from  the  base  of  the  bladder  and  the  urethra.  The 
parts  were  so  adherent  on  the  right  side  that  I  made  a  wound 
in  the  peritoneum,  but  no  coil  of  intestine  came  through.  In 
dissecting  the  growth  from  the  sacrum,  where  also  it  was 
more  firmly  adherent  than  I  anticipated,  I  came  on  the  meso- 
rectum  and  wounded  the  middle  haemorrhoidal  artery,  from 
which  the  rush  of  blood  was  so  great  that  had  I  not  very 
rapidly  seized  it  the  patient  would  have  died  on  the  table. 
The  house  surgeon  administering  the  ether  was  immediately 
aware  of  the  loss  of  blood,  as  the  pulse  failed.  Rather  over 
than  under  five  inches  of  bowel  were  removed.  A  carbolized 
sponge  was  placed  against  the  spot  where  the  peritoneum 
was  wounded,  and  the  cavity,  which  was  very  large  (looking 
as  if  the  whole  interior  of  the  pelvis  bad  been  scooped  out), 
was  also  filled  with  carbolized  sponges.  On  the  day  after 
the  operation  the  patient  was  doing  well,  had  passed  a  fair 
night,  taking  his  nourishment,  not  vomited,  had  a  tranquil 
countenance,  and  was  cheerful.  The  abdomen  was  soft  and 
undistended;  there  was  no  pain  on  pressure  save  near  the 
right  iliac  region,  which  was  rather  tender.  The  next  day 
the  sponges  were  removed,  and  the  wound  carefully  syringed 


CANCER    OF    THE    RECTUM.  223 

out  with  diluted  Condy's  fluid.  There  was  no  sloughing, 
and  the  wound  looked  satisfactory.  On  the  fourth  day 
after  the  operation  he  was  attacked  with  a  severe  rigor  fol- 
lowed by  very  high  temperature  and  sweathing;  symptoms 
of  acute  peritonitis  set  in,  and  he  died  on  the  fifth  day.  A 
post-7no7'tem  showed  acute  peritonitis  all  over  the  abdomen. 
Lymph  was  found  between  all  the  coils  of  the  intestine,  and 
a  purulent  fluid  existed  in  the  pelvis.  The  kidneys  were  not 
quite  healthy.  The  patient  had  no  serious  symptom  until 
the  rigor;  indeed,  a  few  hours  before  he  felt  particularly 
comfortable,  and  I  thought,  on  the  whole,  well  of  him.  A 
trace  of  albumen  had  been  found  in  this  man's  urine. 

Since  the  last  edition  of  this  work  was  published,  I  have 
excised  the  rectum  in  its  entire  circumference  in  six 
patients  only.  Four  operations  were  performed  in  the  years 
1879-80  and  two  during  the  present  year.  The  paucity  of 
recent  operations  is  due  to  a  feeling  of  dissatisfaction,  on 
my  part,  with  the  results  of  those  performed  by  myself  and 
of  those  I  have  seen  done  by  others.  Only  one,  I  believe, 
of  my  sixteen  cases  is  now  living;  he  is  No.  7  of  the  series 
related  in  full.  This  patient  has  had  no  return  of  cancer, 
but  he  is  in  the  most  wretched  condition.  He  has  perpetual 
incontinence  of  faeces,  and  the  rectum,  for  three  inches 
upward  from  the  anus,  is  so  much  contracted  that  unless  he 
constantly  wore  a  tube,  absolute  closure  would  rapidly  take 
place.  In  fact,  if  the  tube  be  left  out  all  night,  great  difficulty 
is  experienced  in  re-introducing  it.  He  is,  as  a  matter  of 
course,  incapable  of  earning  his  livelihood. 

The  method  of  operating  employed  by  me  is  that  which 
has  found  most  favor  with  the  French  authorities.  The 
deep  dorsal  incision  I  really  consider  the  "  key  "  to  the 
operation.  It  gives  you  plenty  of  room,  which  is  essential  if 
you  have  to  remove  any  considerable  length  of  the  rectum, 
and  so  get  fully  above  the  growth.  Further,  it  saves  much 
loss  of  blood,  as  it  enables  you  to  secure  the  vessels_  with 
rapidity  and  certainty.  Lastly,  it  forms  a  deep  drain  or 
channel,  through  which  all  abnoxious  matters  can  freely 
escape.  It  is  the  retention  of  morbific  particles  which  is 
dangerous;  let  them  all  run  away  as  they  are  generated,  and 
you  may  defy  pyaemia  without  any  antiseptics.  In  saying 
this  I  am  not  insensible  to  the  advantages  of  these  chemicals 
when  you  cannot  get  deep  drainage. 

In  operating  on  the  male  I  always  have  a  silver  catheter 
passed  into  the  bladder;  the  assistant  hooks  it  well  up  under 


224  CANCER    OF    THE    RECTUM. 

the  pubic  arch;  the  urethra  and  adjoining  parts  are  thus 
steadied,  and  you  are  enabled  to  carry  on  deHcate  dissections 
without  danger,  in  the  neighborhood  of  the  trigone  of  the 
bladder,  the  prostate,  and  the  urethra.  After  the  operation 
I  think  it  very  advisable  to  place  a  tube  in  the  rectum,  to 
favor  the  escape  of  wind,  which,  if  retained,  will  cause  much 
discomfort  to  your  patient. 

In  women  the  assistant's  finger  ought  to  be  introduced 
into  the  vagina,  to  give  you  timely  warning  when  you 
approach  too  near  the  vaginal  mucous  membrane.  In  most 
of  my  cases  it  was  absolutely  impossible  to  bring  down  the 
stump  of  the  rectum  to  the  skin  ;  if,  indeed,  these  parts 
could  be  brought  together  the  tension  would  be  so  great  that 
the  sutures  would  be  torn  out  in  a  few  hours.  I  cannot 
understand  how  Volkmann  brings  the  rectum  to  the  skin, 
puts  in  sutures,  and  gets  primary  union.  I  can  only  say  that 
the  operation  I  do  must  differ  much  from  Volkmann's.  I 
have  never  used  carbolic  dressings  with  the  view  of  following 
Mr.  Lester  in  his  antiseptic  treatment  ;  in  fact,  these  opera- 
tions appear  to  me  to  be  about  the  very  last  to  which  the 
process,  valuable  as  it  undoubtedly  is  in  some  cases,  is  appli- 
cable. Looking  at  the  chasm  I  make,  and  the  part  in  which 
it  is  made,  I  should  say  that,  shutting  up  the  cavity  by 
sutures,  and  then  endeavoring  to  keep  that  cavity  sweet  and 
healthy  by  drainage  tubes  and  deeper  tubes  put  through 
holes  made  by  the  surgeon,  would  be  making  a  plaything  of 
antiseptic  surgery.  How  can  you  prevent  fecal  matter  from 
getting  into  the  wound,  so  incompletely  closed  as  it  must  be 
by  sutures  ?  Perhaps  it  may  be  said  that  the  bowels  must  be 
kept  confined  for  days  after  the  operation.  To  this  I  would 
answer,  it  is  often  impossible  to  do  so.  The  intestines  of 
these  patients  are  always  in  an  irritable  condition,  and  neither 
opium  nor  any  other  drug  will  delay  action  for  long.  Then, 
again,  I  would  say,  it  is  not  good  to  confine  the  bowels,  for 
should  a  large  mass  form  in  the  upper  part  of  the  rectum, 
such  pressure  on  the  vessels  is  exercised  that  congestion  and 
stasis  are  induced,  and  these  conditions  are  quite  inimical  to 
the  healing  process.  I  am  fully  convinced  that  the  best  after 
treatment  of  these  cases  is  to  establish  a  good  drainage  from 
the  wound,  to  keep  the  parts  clean  by  syringing  with  some 
innocent  disinfectant,  and  if  you  accomplish  this  you  need 
not  fear  ;  the  wound  will  rapidly  fill  up,  and  the  return  will 
grow  downward,  and  unite  with  the  skin. 

My  cases  are  only  sixteen  in  number.     I  will  not,  there- 


CANCER    OF    THE    RECTUM.  22^ 

fore,  draw  definite  conclusions  from  them,  save  that  the 
operation  may  be  accomplished  even  when  the  growths  are 
very  considerable  and  the  adhesions  even  abundant ;  at  the 
same  time,  I  would  point  out  that  there  are  dangers  con- 
nected with  the  operation  not  to  be  despised,  but  which 
increased  knowledge  may  enable  us  more  surely  to  overcome. 
I  would  also  observe  there  is  a  tendency  to  look  too  lightly 
on  the  danger  of  opening  the  peritoneum.  '  In  three  of  my 
cases  that  cavity  was  opened,  and  in  two  no  evil  resulted, 
but  in  the  third  I  have  no  doubt  it  was  the  cause  of  death. 
An  important  question  is.  Do  we  really  obtain  a  cure  in  cases 
of  epithelioma?  My  modest  experience  would  lead  me  to  think 
that  such  a  result  is  very  uncommon,  and  must  not  usually 
be  expected.  A  second  question.  Do  we  obtain  much  pro- 
longation of  life  by  the  operation  ?  I  am  inclined  to  the 
opinion  that  this  question  cannot  be  positively  answered  in 
the  affimative.  Epithelioma  in  many  cases  advances  very 
slowly.  I  have  had  a  considerable  number  of  patients  who 
have  lived  four  years  and  upward  from  the  first  appearance 
of  the  symptoms,  no  operation  having  been  undertaken.  ,If 
the  disease  be  near  the  anus,  not  extending,  say  more  than 
two  inches  up  the  bowel,  I  should  not  hesitate  to  excise  it. 
In  the  large  majority  of  cases,  however,  the  disease  -com- 
mences at  more  than  two  inches  from  the  anus,  and  extends 
for  two  or  three  inches  higher  up.  These  cases  almost 
always  do  badly,,  and  it  therefore  follows  that  the  number  of 
patients  who  can  be  benefited  by  incision  as  the  disease  is 
compartively  small.  Mr.  Rouse,  of  St.  George's  Hospital, 
has  related  a  casein  the  Lancet,  October  2d,  1880,  of  removal 
of  a  small  cancerous  growth  of  the  rectum,  about  an  inch 
from  the  anus,  by  making  a  curved  incision  just  outside  the 
external  sphincter,  and  pushing  the  growth  from  the  rectum 
through  this  opening  ;  it  was  then  cut  off,  and  the  patient 
did  well.  Mr,  John  Gay  has  related  an  almost  exactly  simi- 
lar case,  but  it  is  obvious  that  the  feasibility  of  the  operation 
depends  upon  the  extremely  rare  circumstance  of  the  growth 
being  so  low  down.  Mr.  Gay's  patient,  I  know,  did  not  long 
survive  the  operation,  but  I  do  not  know  how  Mr.  Rouse's 
case  has  terminated.  Mr.  James  Adams,  of  the  London 
Hospital,  has  suggested  that,  prior  to  excising  cancer  of  the 
rectum,  colotomy  should  be  performed.  His  arguments  in 
favor  of  such  a  step  are  briefly  as  follows  :  "  That  in  cases 
of  any  but  of  the  slightest  degree,  the  operation  might  prove 
incomplete  and  the  disease  speedily  return  ;  that  after  com- 

15 


226  CANCER    OF    THE    RECTUM. 

plete  removal  of  the  lower  part  of  the  rectum,  the  subsequent 
contraction  is  often  very  great,  and  sometimes  quite  intract- 
able ;  and  that  in  any  case  the  healing  of  the  wound  would 
be  expedited  and  the  tendency  to  local  recurrence  dimin- 
ished, by  diverting  the  course  of  the  faeces."  The  author 
had  recently  operated  in  a  case  in  which  this  line  of  action 
had  been  adopted  with  the  most  satisfactory  result.  I  am 
inclined  to  think  that  some,  at  all  events,  of  the  published 
cures  were  not  really  cases  of  cancer,  but  lupoid  or  other 
ulcerations.  Probably  a  careful  microscopic  examination  of 
the  removed  growth  would  be  the  only  means  of  deciding  the 
question.  The  -  excision  of  epithelioma  usually  at  once 
relieves  the  patient  of  great  pain,  and  much  comfort  is 
obtained.  As  to  there  being  a  new  sphincter  muscle  formed 
around  the  cut  end  of  the  rectum,  I  do  not  believe  this  ever 
occurs  ;  there  may  be  some  power  of  retaining  fecal  matter 
when  not  liquid,  but  that  only  arises  from  there  always  being  a 
certain  amount  of  contraction,  and  from  the  fact  that  the 
anal  opening  usually  leads  into  a  large  cavity,  where  faeces 
can  rest  for  a  time,  until  expulsive  exertions  are  made.  This 
contraction  is  often  so  considerable  as  to  become  an  obstacle 
to  the  passage  of  excretions,  and  then,  as  in  three  of  my 
cases,  divisions  may  be  called  for,  together  with  the  more^or 
less  continuous  use  of  tubes.  Finally,  is  the  operation  one 
to  be  undertaken  in  ail  cases,  headless  of  the  extent  of  the 
disease,  the  parts  involved,  or  the  age  and  condition  of  the 
patient,  as  some  German  surgeons  practically  assert  ?  I  say 
by  no  means.  The  cases  must  be  carefully  selected  if  any 
lasting  success  is  to  be  obtained. 

The  operation  of  excision  of  the  rectum  and  its  results 
have  been  compared  by  some  surgeons  with  colotomy,  when 
really  there  is  no  ground  for  comparison  ;  both  operations 
may  be  equally  advantageous  in  fit  cases,  but  they  cannot 
be  substituted  the  one  for  the  other  ;  the  most  enthusiastic 
advocate  of  colotomy  would  scarcely  think  of  operating  on 
the  cases  best  fitted  for  excision,  and  the  converse  also 
obtains. 

I  shall  now  proceed  briefly  to  consider  the  subject  of 
colotomy.  This  operation  may  be  done  in  the  inguinal  or 
lumbar  regions,  either  right  or  left.  Inguinal  colotomy  I 
have  never  performed,  except  in  infants,  and  I  have  experi- 
ence of  two  such  cases  only,  neither  of  which  was  very  suc- 
cessful. The  left  lumbar  region,  for  anatomical  reasons,  is 
the  best  suited  to  colotomy,  but  should  the  obstruction  be 


CANCER    OF    THE    RECTUM.  227 

high  Up  the  bowel  the  right  side  may  be  resorted  to.  I  have 
now  thirty-nine  times  performed  colotomy  for  the  relief  of 
patients  suffering  from  cancer,  and  twenty-five  times  in  cases 
of  non-malignant  disease,  sixty-four  cases  in  all.  I  do  not 
see  the  necessity  (the  advantages  of  this  operation  being 
quite  established)  of  relating  my  cases  in  detail.  Most  of 
them  have,  at  various  times,  been  published  in  hospital 
reports  or  the  medical  journals. 

Generally,  I  will  say  that  -colotomy  is  justifiable  when  an 
obstruction  existing  in  the  lower  bowel  threatens  the  patient's 
life  ;  also,  when  an  opening  has  taken  place  between  the  rec- 
tum and  bladder,  or  urethra,  or  even  vaginia  high  up,  the 
distress  in  these  cases  being  exceedingly  great.  (I  have 
recently  had  the  care  of  a  woman,  into  whose  bladder,  by 
some  devious  route,  a  cancer  of  the  rectum  ulcerated,  and 
she  passed  faeces  and  wind  per  urethram.) 

When  a  cancer  of  the  rectum  is  rapidly  advancing,  and 
great  pain  exists  which  ordinary  means  cannot  alleviate,  then 
colotomy  may  be  done  ;  but  I  do  not  think  colotomy  advis- 
able or  justifiable  simply  because  cancer  of  the  rectum 
exists  ;  and  my  large  experience  teaches  me  that  the  idea  of 
prolonging  life  by  a  very  early  opperation  is  erroneous  and 
not  borne  out  by  facts.  When  I  say  my  large  experience,  I 
do  not  speak  of  my  own  operations  alone,  but  of  all  I  have 
seen  others  perform,  and  of  which  I  know  the  ultimate  result. 
I  admit  that  when  obstruction  exists  a  patient  may  be 
snatched  from  immediate  death  by  the  operation,  but  that  is 
not  the  question,  I  mean  can  we  say  to  every  patient  seen 
in  the  early  stage  of  cancer,  "  If  you  will  submit  to  colotomy 
you  will  live  much  longer  than  if  you  do  not  ?  "  I  aver  that 
we  cannot  truthfully  say  this,  and  I  believe  my  position 
proven  by  the  natural  history  of  the  disease,  to  which  I 
directly  refer. 

Of  my  thirty-nine  cases  of  colotomy  in  cancer  the  best 
result  was  obtained  in  a  man  with  a  scirrhous  growth  filling 
up  the  pelvis,  who  lived  four  and  a  half  years  after  the  oper- 
ation. My  second  in  a  woman,  who  lived  nineteen  months, 
and  was  or  twelve  months  in  wonderful  comfort.  Only  five 
of  my  patients  have  died  within  fourteen  days  of  the  opera- 
tion. Two  patients  succumbed  from  phlegmonous  erysipelas. 
In  another  case  the  operation  was  done  when  the  patient  was 
almost  "in  articulo  mortis,"  and  death  took  place  in  ten 
days,  from  exhaustion,  but  the  relief  to  pain  was  so  great 
that  no  regrets  were  felt  by  the  surgeon,  the  patient,  or  the 


228  CANCER    OF    THE    RECTUM. 

friends.  In  the  fourth  the  patient,  a  lady,  died  within  nine 
days  of  the  operation  ;  there  was  entire  obstruction  of  the 
bowel  and  anasarca;  surgical  aid  was  delayed  to  long  ; 
immediately  after  the  colotomy  paracentesis  abdominis  was 
performed.  Acute  pleurisy  was  the  immediate  cause  of 
death. 

In  a  man,  set.  39,  with  cancer  of  the  rectum,  of  epthelial 
character,  I  operated  comparatively  early.  There  was  no 
obstruction,  no  emaciation,  no  detectable  glandular  affection, 
but  he  suffered  great  pain.  The  disease,  or  rather  the  symp- 
toms, I  will  say,  had  existed  only  for  four  months.  The 
patient  recovered  from  the  operation  exceedingly  well,  and 
lived  fifteen  months  after  it,  dying  from  extension  of  the  dis- 
ease, general  blood  poisoning,  and  enlarged  lumbar  glands. 
This  patient  may  fairly  be  said  to  have  died  about  twenty 
months  from  the  commencement  of  the  disease. 

My  observations  on  the  natural  history  of  cancer  in  all 
forms  lead  me  to  conclude  that  the  large  majority  of  victims 
will  die,  /.  e.  the  disease  will  run  its  course  in  about  two  years. 
In  the  case  I  last  mentioned,  pain  was  mitigated  and  acci- 
dents avoided,  but  I  could  not  say  that  life  was  prolonged. 
I  do  not  consider  averages  in  surgical  statistics  of  any  great 
utility,  but  I  may  mention  that  the  average  length  of  life 
after  opertion  in  my  thirty-nine  cases  of  cancer  was  six 
months  and  two  weeks.  However  interesting  this  part  of  my 
subject  may  be,  I  have  neither  time  nor  space  to  pursue  it 
further,  but  shall  turn  to  the  operation  itself. 

The  method  of  opening  the  colon  now  generally  adopted 
is  known  as  Amussat's,  and  was  advocated  by  that  surgeon 
in  his  treatise  published  in  1839,  "On  the  Possibility  of 
Establishing  an  Artificial  Anus  in  the  Lumbar  Region."  In 
the  adult  I  think  there  can  be  no  doubt  that  Amussat's  is  the 
best  procedure. 

By  attention  to  certain  rules,  lumbar  colotomy  will  not  be 
found  very  difficult,  but  the  not  infrequent  occurrence  of 
misadventures  induces  in  my  mind  the  belief  that  many  sur- 
geons are  not  yet  sufficiently  alive. to  the  necessity  for  con- 
siderable precision  in  the  performance  of  this  operation, 
more  especially  when  the  bowel  is  undistended. 

The  directions  usually  afforded  in  works  on  surgery  lack 
the  element  of  precision,  which  I  think  indispensable.  The 
error  usually  made  in  operating  is  to  search  for  the  colon  too 
far  from  the  spine  ;  the  result  of  this  is,  that  the  peritoneum 
is   inadvertently  opened,  a  coil  of  small  intestine  at  once 


CANCER    OF    THE    RECTUM.  229 

shoots  up  into  the  wound  ;  this  misleads  the  surgeons  and 
renders  the  discovery  of  the  colon  more  difficult  as  well  as 
the  operation  more  likely  to  prove  fatal. 

The  anatomical  guide  to  the  position  of  the  ascending  or 
descending  colon  is  the  free  edge  of  the  quadratus  lumborum 
muscle,  but  this  is  by  no  means  always  easily  found,  and  con- 
sequently it  is  better  to  substitute  a  more  certain  and  unmis- 
takeable  guide,  and  this,  as  I  have  stated  in  my  article  on 
colotomy  in  the  "St.  Thomas's  Hospital  Reports"  for  1870, 
may  be  obtained  by  marking  a  spot  on  the  crest  of  the  ilium, 
fully  half  an  inch  posterior  to  a  point  midway  between  the 
two  superior  spinous  processes. 

From  more  than  fifty  dissections  and  the  experience  of 
over  eighty  operations  of  my  own  and  others,  I  can  confi- 
dently assert  that  the  colon  is  always  normally  situated  oppo- 
site this  point. 

Before  operating  I  mark  this  spot  on  the  crest  of  the  ilium 
with  ink  or  iodine  paint,  and  I  have  always  found  it,  when 
the  superficial  tissues  are  divided,  a  most  useful  landmark 
and  guide  to  the  exact  position  of  the  intestine.  This  is 
especially  valuable  if  you  fail  to  recognize  the  deeper  struc- 
tures as  they  are  incised,  which  you  may  easily  do  if  the 
patient  be  muscular  or  fat.  On  the  whole  I  prefer  the 
oblique  incision,  as  recommended  by  Mr.  Bryant,  downward 
from  the  last  rib  toward  the  anterior  superior  spinous  process 
of  the  ilium,  and  the  centre  of  this  cut,  which  should  be 
made  from  three  to  four  inches  in  length,  must  be  opposite 
your  mark  upon  the  crest.  When  the  intestine  is  at  all  dis- 
tended I  make  my  incision  not  more  than  two  inches  in 
length,  and  I  find  this  quite  sufficient. 

When  about  to  operate  the  patient  should  be  placed  upon 
a  hard  couch,  in  the  prone  position,  with  a  slight  inclination 
toward  the  right  side,  and  a  hard  pillow  is  to  be  adjusted 
under  the  left  side,  so  as  to  render  the  loin  tense  and 
prominent. 

I  have  frequently  seen  the  operator  stand  behind  the 
patient.  I  prefer  standing  in  front,  in  which  position  I 
think  you  are  less  likely  to  make  your  deeper  incisions 
too  far  forward,  and  so  inadvertently  open  the  peritoneum. 

The  structures  should  be  very  carefully  divided  on  a 
director,  and  this  should  be  done  slowly  and  deliberately, 
waiting  until  bleeding  be  arrested,  so  that  the  anatomical 
relation  of  the  parts  be  duly  recognized  as  the  operation 
proceeds.     I  think  it  very  desirable,  though  not  absolutely 


230  CANCER    OF    THE    RECTUM. 

necessary,  that  the  fascia  lumborum  should  be  thoroughly 
made  out,  and  if  possible  the  edge  of  the  quadratus  lum- 
borum muscle  clearly  exposed.  If  this  is  seen  a  blunt- 
pointed  bistoury  should  be  passed  beneath  it  and  the  muscle 
freely  divided;  when  this  is  done  the  colon  will  be  found;  it 
is  generally  covered  by  fat,  which  may  be  mistaken  for  the 
gut,  but  this  error  will  be  soon  discovered  and  is  very  easily 
rectified.  It  is  of  the  utmost  importance  that  the  deeper 
incisions  be  kept  the  same  length  as  the  cut  through  the 
skin.  If  you  do  not  attend  to  this  rule,  by  the  time  you 
reach  the  lumbar  fascia  you  will  be  working  in  a  deep  trian- 
gular hole,  the  apex  of  which  is  furthest  from  you;  and  it 
will  be  almost  impossible  to  find  the  gut,  even  if  you  have 
come  down  upon  the  right  spot.  From  personal  experience, 
and  the  many  operations  I  have  seen  performed  by  other 
surgeons,  I  am  quite  convinced  that  this  is  the  secret  of 
overcoming  the  difficulties  of  the  operation.  If  the  colon  be 
fairly  exposed  as  I  have  directed,  there  is  usually  but  little 
difficulty  in  recognizing  it,  even  when  it  is  quite  undistended, 
and  picking  it  up  from  the  bottom  of  the  wound.  In  most 
of  my  cases  one  of  the  longitudinal  bands  was  clearly 
observed,  and  in  others  hard  portions  of  faeces  could  be  felt 
before  the  gut  was  opened. 

The  intestine  having  been  found,  it  should  be  drawn  well 
out  of  the  wound,  and  opened  longitudinally  for  about  an 
inch,  the  edges  of  the  incision  being  stitched  to  the  edges  of 
the  skin.  The  sutures  should  be  passed  through  the  colon 
before  opening  it,  to  avoid  any  chance  of  the  contents  run- 
ning into  the  wound.  I  have  found  thick  silk  sutures  answer 
better  than  wire,  as  they  do  not  so  easily  cut  their  way  out, 
and  I  retain  them  until  I  observe  that  they  have  begun  to 
ulcerate  through  the  skin;  but  it  is  better  not  to  keep  them 
in  too  long;  forty-eight  hours  is  usually  sufficient. 

The  immediate  fatality  of  the  operation  depends  almost 
wholly  upon  whether  any  fecal  matter  or  morbific  fluid  runs 
into  the  peritoneal  cavity;  therefore  it  should  be  remem- 
bered that  it  is  desirable  to  approach  the  colon  on  its  dorsal 
or  even  spinous  aspect,  rather  than  upon  its  outer  side,  and 
to  avoid,  by  all  means  in  your  power,  opening  the  perito- 
neum. 

When  the  intestine  is  collapsed  I  have  recommended  a 
quantity  of  fluid  to  be  injected,  but  I  must  now  qualify  that 
advice,  and  say  it  is  better  to  endeavor  to  distend  the  gut 
with  air  if  you  cannot  find  it  without 


CANCER    OF    THE    RECTUM.  23! 

If  the  case  goes  on  fairly  well  the  after-treatment  is  gener- 
ally very  simple.  I  usually  apply  a  weak  solution  of  car- 
bolic acid  or  Condy's  fluid  to  keep  the  part  from  getting  dry 
and  stiff  and  to  deodorize,  as  the  smell  is  sometimes  very 
unpleasant.     A  charcoal  poultice  is  often  very  advantageous. 

When  the  bowels  have  been  long  confined  before  the 
operation,  they  are  occasionally  very  difficult  to  get  to  act, 
and  you  may  have  to  employ  a  scoop  to  remove  the  indur- 
ated fecal  lumps;  this  being  accomplished,  enemata  may  be 
used  to  stimulate  the  colon  to  action,  and  relief  will  be 
obtained. 

The  patient  is,  as  a  rule,  able  to  get  about  in  four  weeks 
from  the  time  of  the  operation. 

When  up  they  may  wear  a  well-fitting  india-rubber  pad,  to 
prevent  the  escape  of  wind  and  motion.  I  now  have  the 
pad  made  a  little  hollow  and  fill  the  concavity  with  cotton 
wool,  which  will  absorb  any  slight  moisture  and  keep  the 
part  dry.  Some  of  my  patients  preferred  merely  a  pad  of 
wool  and  a  napkin  over  it,  to  any  mechanical  appliance.  It 
is  a  great  thing  to  cultivate  the  habit  of  getting  the  bowels 
to  act  the  first  thing  in  the  morning;  by  this,  incontinence 
and  trouble  during  the  day  are  best  avoided. 

I  always  recommend  the  use  of  plenty  of  cold  water,  night 
and  morning,  to  the  lumbar  aperture;  by  which  means  the 
mucous  membrane  may  be  .kept  healthy  and  the  probability 
of  protrusion  of  the  gut  be  lessened.  This,  however,  if  the 
patient  should  survive  the  operation  for  many  months,  is 
certain  to  occur  to  a  greater  or  less  extent;  generally  it  can 
be  returned  by  gentle  pressure,  but  sometimes  it  can  be 
replaced  only  by  passing  a  softened  bougie  or  thick  tallow 
candle  and  carrying  the  bowel  upward. 

Since  I  have  made  a  much  smaller  external  incision  I  have 
not  found  the  protrusion,  as  a  rule,  so  troublesome,  but  still 
it  will  occur. 

Among  the  most  distressing  symptoms  attending  cancer  of 
the  rectum  must  be  numbered  violent  straining.  I  had 
anticipated  that  colotomy  would  entirely  remove  this  cause 
of  suffering,  but  that  is  by  no  means  the  case.  The  cancer- 
ous growth,  especially  when  it  approaches  the  anus,  pro- 
vokes reflex  action,  and  irresistible  bearing-down  results; 
this  also  is  the  case  when  fecal  matter  passes  the  opening  in 
the  loin  and  accumulate  in  the  bowel  below.  This  was 
supposed  to  be  almost  an  impossibility,  but  in  my  experi- 
ence it  is  of  frequent  occurrence,  and  causes  severe  pain  as 


232  RODENT    OR    LUPOID    ULCER. 

well  as  straining.  In  a  case  I  had  with  Mr.  Aikin  it  was  one 
of  the  evils  we  had  always  to  combat,  and  it  rendered 
syringing  out  the  rectum  from  the  anus  a  matter  of  daily 
necessity,  and  added  much  to  the  patient's  suffering.  In 
such  conditions  the  treatment  must  consist  in  keeping  the 
rectum  as  clear  of  motion  as  possible,  by  frequent  washing 
out  with  warm  water  and  some  disinfectant,  the  particular 
one  used  being  changed  from  time  to  time.  I  think,  on  the 
whole,  carbolic  acid  is  the  worst  you  can  employ,  as,  even 
when  extremely  weak,  it  is  liable  to  set  up  irritation  in  the 
cancerous  growth  in  the  bowel  and  a  consequent  increase  of 
local  pain.  Salicylic  acid  and  thymol  I  find  good,  but  on 
the  whole  I  prefer  a  solution  of  permanganate  of  potash, 
which  is  soothing  to  the  part  and  readily  destroys  odor,  and 
has  no  unpleasant  attributes  in  itself.  Surgeons  are  too  apt 
to  forget  that  when  colotomy  is  performed  the  cancer  is  still 
left  in  the  bowel,  and  attention  must  be  directed  to  this. 
The  discharge  must  be  removed  by  careful  syringing,  and 
great  relief  may  be  given  to  the  patient  by  injections  of 
watery  solutions  of  opium  and  other  sedatives,  per  a?ium. 
The  patients  should  live  well,  and  I  always  order  as  much 
cod-liver  oil  as  they  can  take  without  disturbing  the  stomach. 


CHAPTER  XIX. 

RODENT  OR  LUPOID  ULCER. 

Although  some  of  my  critics  have  taken  exception  to  the 
word  "rodent,"  I  cannot,  on  reconsideration,  find  a  more 
appropriate  appellation,  unless  it  be  "  lupoid,"  but  I  think 
the  term  is  not  so  very  important.  What  I  wish  to  do  is  to 
describe  and  define  a  species  of  ulcer  of  the  rectum  not 
often  met  with,  which  is  totally  distinct  from  simple  ulcer, 
and,  in  my  opinion,  is  very  nearly  allied  to  epithelial  cancer, 
although  it  differs  from  that  malady  in  several  essential  par- 
ticulars which  I  will  presently  detail. 

In  its  early  stage  the  ulcer  is  very  difftcult  to  distinguish 
from  a  syphilitic  sore,  and  when  it  is  situated  just  within  the 
sphincter  it  may  also  readily  be  mistaken  for  the  ordinary 
painful  rectal  ulcer.    Rodent  ulcer  in  the  rectum  differs  from 


RODENT    OR    LUPOID    ULCER.  233 

the  malady  of  the  same  name  found  on  the  face,  in  being,  as 
a  rule,  most  terribly  painful,  and  in  having  no  indurated 
margin;  it  also  differs  in  another  essential  and  important 
point — it  is  very  much  less  curable;  as  far  as  I  know,  it  is 
nearly  as  deadly  as  cancer,  though  not  so  rapid  in  its  pro- 
gress. I  cannot  say  that  I  ever  saw  a  case  of  undoubted 
rodent  ulcer  of  the  rectum  cured,  but  I  have  now  a  ease 
which  has  remained  well,  after  excision,  for  more  than  four 
years. 

It  is  a  happy  thing  that  the  disease  is  an  uncommon  one  ; 
in  my  own  practice  I  have  had  only  nine  decided  cases,  and 
I  do  not  remember  to  have  seen  more  than  fourteen  in  all. 

Rodent  or  lupoid  ulcer  may  be  distinguished  from  epithe- 
lioma by  the  following  peculiarities  :  It  does  not  invade 
neighboring  organs  by  infiltration,  nor  does  it  contaminate 
through  the  lymphatics  ;  as  far  as  I  know,  it  never  forms 
secondary  deposits,  and  it  produces  no  hardness.  It  is  not, 
I  am  informed  by  microscopists,  a  disease  of  the  follicles  of 
the  rectum. 

It  differs  from  secondary  or  tertiary  syphilitic  ulceration 
in  not^  inducing  stricture  of.  the  rectum  or  any  submucous 
thickening;  and  this  difference  arises  from  its  being  essen- 
tially a  destructive  ulceration,  no  long-continued  effort  at 
repair  which  would  cause  permanent  deposits  taking  place. 

The  appearance  of  the  ulcer  is  peculiar,  and  there  need 
be  but  little  hesitation  in  deciding  what  it  is  when  once  it  is 
fairly  established,  but  as  I  have  said,  in  the  earliest  stage, 
the  most  experienced  pathologist  may  be  at  fault. 

The  following,  from  my  observations,  I  should  say  are  the 
characteristics  of  the  sore:  the  shape  is  usually  irregular;  I 
have  only  once  seen  it  quite  circular  and  symmetrical;  this 
occurred  in  a  case  which  I  shall  presently  relate.  Its  edges 
are  sharp  and  cleanly  cut;  it  does  not  undermine  the  mucous 
membrane;  it  destroys  completely,  as  far  as  it  extends; 
neither  its  edge  nor  its  base  is  at  all  hard,  and  the  mucous 
membrane  around  it  is  perfectly,  and  I  may  say  abruptly, 
healthy.  Its  surface  is  very  red  and  mostly  dry;  there  is 
scarcely  ever  any  amount  of  discharge  from  it.  It  sometimes 
destroys  deeply,  but  its  tendency  is  to  spread  superficially 
and  to  attack  mucous  membrane  rather  than  skin,  though  in 
some  of  the  cases  I  have  observed  it  invaded  the  border-land 
mucous  membrane  and  skin,  and  it  may  spread  even  to  a 
considerable  distance  on  the  latter.  It  often,  for  a  time, 
remains  stationary,  and  I  have  noticed  repair  taking  place 


234  RODENT  OR  LUPOID  ULCER. 

very  rapidly,  but  just  as  you  think  cicatrization  will  be  com- 
pleted, all  the  granulations  will  melt  away,  like  snow  before 
the  sun,  and  the  ulcer  will  appear  in  its  former  shape  and 
character  in  the  course  of  a  few  hours. 

The  patients  attacked  by  this  disease  I  think  I  may  say  are 
nearly  always  of  a  markedly  scrofulous  diathesis. 

'Rodent  ulcer  is  generally  most  horribly  painful  (I  have 
seen  only  one  exception  to  this);  the  sufferer  describes  it  as 
a  constant,  burning,  gnawing  sensation,  as  if  a  red-hot  iron 
were  applied  to  the  part.  Of  course,  the  pain  is  aggravated 
when  the  bowels  act.  Death  takes  place  from  exhaustion; 
the  patient  really  appears  to  die  from  the  never-ceasing  suf- 
fering. Two  of  my  cases  had  diarrhoea  toward  the  termi- 
nation of  their  lives,  and  this  rapidly  carried  them  off. 
Phthisis  was  the  cause  of  death  in  three  others.  The  treat- 
ment generally  adopted  for  this  disease  has  been  the  appli- 
cation of  escharotics,  such  as  nitric  acid,  chloride  of  zinc, 
arsenite  of  copper,  the  actual  cautery,  etc.  And  if  you  burn 
the  sore  well  out  the  patient  usually  has  for  a  time  much 
freedom  from  pain.  One  of  my  patients  was  comparatively 
comfortable  for  three  months  after  the  use  of  fuming  nitric 
acid,  but  of  all  escharotics  I  think  the  best  are  the  chloride 
of  zinc  (used  after  Fell's  plan)  and  the  arsenite  of  copper ; 
but  even  these,  in  my  experience,  will  only  delay  the  malady, 
but  do  not  cure  it.  Internal  remedies  are  advantageous, 
such  as  tonics,  cod-liver  oil,  sedatives,  etc.,  but  they  only 
lend  a  feeble  help.  Specifics  are,  in  my  Oj,- inion,  worse  than 
useless;  I  believe  the  only  plan  worth  trying  now  is  exceed- 
ingly free  incision.  Should  a  case  come  to  me,  I  should, 
with  my  present  knowledge,  perform  extirpation  of  the  lower 
part  of  the  rectum.  The  only  patient  I  have  had  do  well 
was  a  Greek  gentleman,  who  came  to  me  in  February,  1875, 
and  from  him  I  removed  two-thirds  of  the  circumference  of 
the  rectum  dorsally,  where  a  well-marked  rodent  ulcer ' 
existed.  He  had  consulted  many  eminent  men,  and  all 
kinds  of  treatment  had  been  tried  internally  and  externally 
without  benefit.  The  sore  had  existed  twelve  months  at 
least  when  I  first  saw  him.  I  have  excised  rodent  ulcers 
before,  but  never  so  freely,  and  I  now  think  my  operations 
had  not  been  radical  enough.  In  the  above  instance  I 
removed  all  the  coats  of  the  rectum,  and  even  fat,  and  cut 
at  least  an  inch  all  round  away  from  the  sore.  When  I  last 
heard  of  the  patient,  four  years  after  the  operation,  there  had 
been  no  return  of  the  sore,  and  the  patient's  general  health 


RODENT   OR   LUPOID   ULCER.  235 

was  very  good.  In  another  case  where  I  performed  free 
excision  a  year  ago  there  has  been  no  return  of  the  growth. 

In  my  opinion  some  cases  that  occurred  to  me  years  ago 
are  so  typical,  and  illustrate  so  well  the  disease,  that  I  shall 
not  relate  in  detail  any  of  later  date. 

Mrs.  H ,  set.  30,  a  delicate-looking,  nervous,  excitable 

woman,  of  strumous  diathesis.  She  has  three  children,  the 
youngest  being  two  years  of  age.  She  has  never  had  any 
miscarriages  or  any  serious  illness  prior  to  her  present  one; 
but  considers  herself  as  delicate,  and  suffers  much  from  sore 
throat.  Six  months  ago  she  was  supposed  to  have  fissure  of 
the  rectum,  and  an  operation  was  performed  upon  her  by  a 
very  skillful  surgeon,  but  she  did  not  get  well.  She  was  bet- 
ter for  a  time,  but  the  pain  has  returned,  and  she  feels  much 
as  she  did  before  being  operated  upon. 

On  examining  her  I  found  an  inflamed-looking  ulcer  at  the 
entrance  of  the  anus;  it  was  partially  external,  about  one- 
third  being  outside  and  the  rest  inside.  It  was  three-quarters 
of  an  inch  long  by  about  half  an  inch  wide;  it  was  quite 
superficial,  and  was  not  at  all  hard.  The  sphincter  ani  was 
spasmodically  contracted;  she  suffered  a  good  deal  of  aching 
pain,  worse  after  action,  and  the  bowels  were  very  confined. 
There  was  no  polypus.  I  decided  to  divide  the  sphincter 
freely.  My  friends,  Dr.  Crosby  and  Mr.  Shillitoe,  who 
assisted  me  at  the  operation,  were  strongly  of  opinion  that 
the  sore  was  syphilitic.  I  have  mentioned  that  she  had  sore 
throat,  but  she  had  no  rash,  and  there  was  no  history  of 
syphilis.  The  uterus  was  found  to  be  quite  healthy.  This 
lady's  husband  had  not  been  a  steady  man,  and  therefore  it 
was  by  no  means  certain  that  she  had  not  been  infected  ;  so 
it  was  agreed  that  she  should  take  the  bichloride  of  mercury 
with  tonics  and  cod-liver  oil. 

The  operation  at  once  relieved  the  pain,  and  she  went  on 
very  satisfactorily.  The  wound  looked  healthy,  granulated 
freely,  and  I  saw  no  reason  why  she  should  not  do  well; 
but  after  about  five  weeks  the  sore  became  stationary,  and 
refused  to  answer  to  stimulating  lotions;  moreover  she 
began  to  suffer  from  her  old  pain,  which  she  always  described 
as  being  like  "  a  red-hot  iron  applied  to  the  part."  I  may 
say  that  the  wound  had  healed  up  to  nearly  the  dimensions 
it  was  when  I  operated.  I  had  now  pretty  well  made  up 
my  mind  as  to  the  character  of  the  ulcer,  so,  when  at  the 
end  of  three  months  I  found  it  still  no  better,  but  rather 
increasing  in  size,  I  determined  to  cleanly  excise  the  whole 


236  RODENT    OR    LUPOID    ULCER. 

sore.  Again,  assisted  by  the  same  gentlemen,  I  freely 
removed  the  ulcer,  cutting  wide  of  it,  and  removing  the  base 
fully  down  to  the  cellular  tissue,  taking,  of  course,  nearly 
all  of  one-half  of  the  external  sphincter  muscle  away.  After 
this  I  well  swabbed  the  wound  with  a  strong  solution  of 
chloride  of  zinc.  Both  Dr.  Crosby  and  Mr.  Shillitoe  agreed 
that  it  was  impossible,  by  the  incision  I  had  made,  not  to 
have  removed  all  the  diseased  parts.  After  this  operation, 
for  three  months,  the  patient  went  on  well,  and  the  sore 
healed  up  to  nearly  its  original  size,  when  it  again  halted, 
and  the  pain  returned  as  badly  as  ever.  My  colleague,  Mr. 
GowUand,  now  saw  her  in  consultation  with  me,  and  was 
much  inclined  to  give  a  favorable  prognosis,  but,  on  taking 
the  case  in  hand  himself,  he  soon  found  that  no  remedy  he 
had  knowledge  of  was  of  any  avail.  This  lady  afterwards 
consulted  many  eminent  surgeons,  but  without  deriving  any 
benefit,  and  she  died  in  about  three  years  from  the  com- 
mencement of  her  illness,  under  the  care  of  the  late  Mr.  De 
Morgan,  in  the  Harley  Street  Surgical  Home  for  Ladies. 

A  girl,  set.  17,  who  came  from  the  country,  was  taken 
into  St.  Mark's  Hospital,  under  my  care,  in  the  summer  of 
1867.  She  was  a  ruddy-complexioned,  heavy,  rather  stupid, 
strumous  looking  person,  and  we  had  a  good  deal  of  diffi- 
culty in  extracting  any  information  from  her.  She  had  a 
sore  just  at  the  verge  of  the  anus,  toward  the  perineum,  and 
it  had  burrowed  through  into  the  vagina,  close  to  the  four- 
chette.  She  did  not  know  how  long  it  had  existed.  She 
professed  to  be  very  innocent,  and  strongly  denied  any  pos- 
sibility of  syphilis,  but  she  had  no  appearance  of  a  hymen, 
and  her  vagina  was  capacious.  She  had  a  superficially 
ulcerated  throat,  and  some  spots  of  a  suspicious  character 
on  her  head  and  on  her  body.  She  had  no  enlarged  glands 
in  her  groins;  she  complained  of  a  great  deal  of  pain  in  the 
sore.  .  I  made  but  little  doubt  of  its  being  syphilitic,  and 
prescribed  an  antisyphiltic  treatment;  finding  no  improve- 
ment take  place,  I  passed  a  director  through  the  sinus  and 
laid  it  open — still  it  did  not  heal.  Mr.  James  Lane,  who 
was  then  one  of  my  colleagues,  saw  it,  and  agreed  with  me 
as  to  its  being  a  syphilitic  sore,  so  I  persevered  with  the  rem- 
edies for  some  time  longer,  but  it  did  not  heal,  and  I  began 
to  have  my  suspicions  that  I  had  made  an  incorrect  diagno- 
sis. I  then  treated  the  ulcer  freely  with  strong  nitric  acid, 
and  for  a  time  it  greatly  improved,  and  she  suffered  scarcely 
any  pain;  and  then  all  of  a  sudden,  without  any  apparent 


RODENT    OR    LUPOID   ULCER.  237 

cause,  the  sore  spread  and  extended  up  the  bowel,  as  well  as 
the  vaghia,  removing  the  tissues  rather  deeply.  She  rapidly 
lost  flesh,  became  very  weak,  and  had  almost  constant  pain, 
which  was  only  slightly  mitigated  by  hypodermic  injections 
of  morphia.  I  kept  her  in  the  hospital  for  a  long  while,  but 
finally,  at  her  own  resquest,  I  sent  her  home,  and  I  was 
informed  that  she  did  not  live  very  long. 

A  man,  aet.  42,  of  delicate  and  feeble  appearance,  was  an 
out-patient  of  mine  at  St.  Mark's.  He  had  been  ill  for 
about  twelve  months,  and  had  been  in  several  hospitals. 
He  had  ulceration  of  the  rectum,  superficial  but  extensive; 
dorsally  it  extended  up  the  bowel  for  quite  two  inches,  and 
laterally,  on  both  sides  for  about  an  inch;  the  skin  exter- 
nally was  slightly  involved;  there  was  no  constriction  of  the 
bowel,  and  no,  and  no  deposits;  the  sore  had  a  very  dry 
and  red  appearance;  it  discharged  a  sanious  fluid,  but  no 
pus.  He  suffered  most  horribly,  scarcely  ever  had  a 
moment's  ease,  and  he  took  all  the  morphia  he  could  get. 
He  would  not  come  into  the  hospital  to  have  anything  done; 
all  he  prayed  for  was  something  to  relieve  his  pain.  I 
taught  him  to  use  the  hypodermic  syringe  upon  himself,  and 
he  obtained  some  ease  from  that.  When  he  became  too 
weak  to  come  to  the  hospital  I  visited  him  at  home,  wishing 
much  to  be  allowed  to  examine  the  body  after  death,  but 
when  that  event  occurred,  his  friends  would  not  accede  to 
my  request.  He  died  of  diarrhoea;  there  was  no  evidence 
of  any  secondary  deposits  having  taken  place. 

John  S ,  a  gunner  in  the  Royal  Artillery,  set.  31,  was 

sent  to  me  at  St.  Mark's,  January,  1872,  from  the  hospital  at 
Shoeburyness.  The  history  is  that  he  has  been  in  India  for 
six  years,  and  returned  to  England  twelve  months  back. 
While  in  India  he  had  diarrhoea,  fever,  and  smallpox,  but 
never  dysentery,  always  enjoyed  good  health;  he  is  a  steady 
man,  single,  and  of  very  good  character  in  the  army.  He 
cannot  quite  assign  any  date  to  his  rectal  affection,  but  had 
piles  in  India,  and  some  operation  was  performed  for  their 
cure;  after  this  he  was  but  little  troubled  until  a  few  months 
before  he  returned  to  this  country.  He  has  been  six 
months  in  the  military  hospital  without  any  improvement  in 
his  condition.  He  has  never  had  syphilis,  but  has  had  gon- 
orrhoea. 

He  is  a  middle-sized,  slight,  spare  man,  much  marked  by 
smallpox,  aspect  not  very  unhealthy.  An  examination  of 
the  chest  detected  dullness  at  the  upper  part  of  the  right 


238  RODENT  OR  LUPOID  ULCER. 

lung;  he  is  rather  subject  to  cough  and  there  is  phthisis  in 
his  family,  but  he  has  never  suffered  from  haemoptysis  or 
inflammation  of  the  lungs.  On  separating  the  buttocks  a 
perfectly  symmetrical,  nearly  circular  sore  is  seen  extending 
all  round  Ae  anus;  it  is  as  large  as  a  five-shilling  piece,  very 
superficial,  with  a  well-defined  edge;  the  sore  discharges  but 
little  pus,  is  remarkably  clean  and  red,  and  is  covered  by 
rather  largish  granulations.  The  anus  is  more  patulous  than 
natural,  and  the  ulceration  is  found  to  extend  up  the  bowel 
for  nearly  an  inch;  above  this  the  mucous  membrane  is 
quite  healthy.  There  is  not  the  slightest  induration  about 
tiie  sore.  The  sphincter  is  very  relaxed  and  powerless,  and 
the  patient  states  that  when  the  motions  are  loose  he  has 
but  little  control  over  them.  There  is  no  evidence  of  sj^ph- 
ilis;  he  has  no  rs?n  sore  throat,  or  enlarged  glands.  He 
does  not  surer  se  7  r  in.  but  there  is  a  constant  burning 
in  the  part  :  _ _::   zted  by  any  movement  and  by 

the  action    ;:    :    t  t  f      H:?  appetite  is  fair;  he  sleeps, 

but  his  nig:.  ^  t  i  f : :::  e  i  r. : :  actually  by  acute  pain,  but 
bynneaanesf       i      z     f  e  sore.     He  has  been  grad- 

ually losing  r  1 5     ;  :..z  i::- - _    . 

Many  en   rt":     urrt:    -  :  .  I  showed  this  patient 

directly  t  r : :. :  -  t  i  :':.-  5 : : t  :  t  syphilitic,  but  a  further 
inve?^r  :.  :.  :-i::ri  :  e  ..  -;  ::.  iraw  that  opinion,  and 
the:::::";  r:r  :":  :::i  ::  :  ::::i:  ::::  it  was  rodent  ulcer. 
Iir::_-i:Ti  '.':.-  ::::t":  :::  ::t  i  _'::-rT  :^rom  the  sore, 
but  :::f  rr::z  ::  :  '  ;   ft:-::"t   :  ;Tri:::i.£  ":"::-£  negative. 

Tt    :t   :     t  ^  i:de  of  potassium  with  bark 

;r  :     :  :-       :  ::       :r  :'  stimulant  and  sedative 

:         5   ::    '':.-   :::e  :  i  ;.  -O  benefit  r^mlting,  the 

It  :     :      :  i   Z  : :.     an's  solution  was  adminis- 

t::     :        :::     tt     t     ::  '1-     :  ":  avaiL 

I  It  : ::  i  i  ;:::::  ::  '.:.z  .tt  with  the  fuming  nitric 
1:  i  :  :  r:  r:  ::  ement  took  place;  therefore  I  did  not 
1:  '     'le  whole  sore. 

7  T  T :.  : ::  the  hospital  for  about  four  months, 

;i.i  lespite  all  that  was   done   for  him  he  got  gradually 

:  T      The  pain  was  mitigated  by  sedatives,  but  it  became 

: .  :t  —Tie  smd  almost  constant;  he  lost  flesh  and  strength, 

and  the  ulcer  increased  in  size  until,  when  he  left,  it  was 

'  ree  inches  in  diameter;  and  deeper  than  at  first;  it 

ad  much  extended  up   the   rectum.     He  went    to 

the    Herbert     Hospital    at     Woolwich,     and     1     heard, 

some  rj. ::.:'?  afterwards,  from  the  gentleman  under  whose 


VILLOUS   TUMOR   OF   THE   RECTUM.  239 

care  he  was,  that  he  died;  no  post-mortem  examination  was 
made. 

I  am  strongly  of  opinion  that  I  can  do  much  more  for 
the  cure  of  the  disease  now  than  I  could  when  the  above- 
mentioned  patients  came  under  my  care;  my  treatment 
would  be,  if  possible,  very  free  excision  of  the  whole  of  the 
diseased  portion  of  the  bowel. 


CHAPTER  XX. 

VILLOUS   TUMOR    OF    THE    RECTUM. 

This  is  a  rare  but  interesting  disease.  Mr.  Quain,  in  his 
work,  gives  the  details  of  the  only  case  that  had  fallen  under 
his  observation.  I  have  now  seen  fourteen  examples  of  this 
growth — eight  in  my  own  practice,  three*  in  St.  Mark's  Hos- 
pital, under  the  care  of  my  colleague,  Mr.  Gowlland,  one  in 
my  colleague,  Mr.  Alfred  Cooper's  practice,  and  two  under 
Mr.  Goodsall's  care. 

The  leading  symptoms  may  be  stated  to  be  the  descent  of 
a  tumor,  usually  on  the  bowels  acting,  or  even  when  the 
patient  walks,  and  the  very  abundant  discharge  of  a  glairy 
mucous  resembling  the  white  of  an  unboiled  egg.  This 
latter,  in  all  my  cases,  and  in  Mr.  Gowlland's  also,  was  the 
most  prominent  symptom  ;  even  when  the  tumor  was  not 
protruded  from  the  anus,  this  discharge  frequently  ran  away 
from  the  patient  without  his  having  control  over  the  escape  ; 
it  is  evidently  a  very  great  exaggeration  of  the  normal  secre- 
tion of  the  mucous  membrane  of  the  rectum  by  the  villi  which 
grow  from  it  and  from  the  tumor. 

Blood,  in  some  of  my  cases,  was  lost  in  quantity,  two  of 
my  patients  being  quite  blanched  from  that  cause,  but  I 
would  observe  that  even  the  loss  of  the  mucus  is  a  severe 
drain  upon  the  constitution,  and  shows  itself  in  the  aspect  of 
the  patient.  Exceedingly  large  arteries  may  usually  be  felt 
entering  the  broad  peduncle  of  the  growth.  It  does  not 
appear  that  pain  usually  attends  this  disease,  only  discom- 
fort arising  from  the  protrusion  and  constant  discharge.  The 
tumor  consists  of  alobulated,  spongy  mass,  with  long  villous- 
like   groups  studding  its  surface  ;    it   resembles    exactly — 


240  VILLOUS    TUMOR    OF    THE    RECTUM. 

though  the  villi  are  much  larger — the  growth  of  the  same 
name  found  in  the  bladder.     Usually  it  is  attached  to  the 

bowel  by  a  stem,  broad  rather  than  round,  and  this  appears 
to  me  to  be  more  like  an  elongation  or  dragging  down  of  the 
mucous  membrane  and  sub-mucous  tissue  than  a  develop- 
ment. The  flattened  peduncle  may  be  two  or  three  inches 
in  length,  or  it  may  be  short  ;  in  two  of  my  patients  it  was 
quite  short,  indeed  ;  the  tumor  itself  came  outside,  but  grew 
directly  from  the  surface  of  the  bowel. 

In  cases  where  the  growth  arises  from  the  perineal  sur- 
face, as  a  practical  point  worth  remembering,  I  should  say  it 
is  by  no  means  impossible  that  a  pouch  of  peritoneum  may 
be  dragged  down  into  the  pedicle,  and  in  such  a  case,  if  the 
ligatures  were  applied  close  to  the  bowel,  peritoneum  might 
be  tied  up  with  it. 

When  the  second  edition  of  this  work  was  published,  from 
what  I  had  seen  and  heard,  I  was  of  opinion  that  these 
tumors,  when  removed,  did  not  return.  I  am  obliged  now 
to  modify  that  opinion,  as  I  am  also  to  the  large  losses  of 
blood  occasionally  attending  them.  I  am  also  compelled  to 
express  the  opinion  that  they  may  become  malignant,  having 
now  seen  two  cases  in  which  epithelioma  replaced  the  villous 
growth.  From  a  case  I  have  had  I  think  it  very  probable 
that  these  growths  sometimes  shed  themselves,  and  the 
patient  may  remain  well  after  this  for  a  considerable  time. 
Supposing  that,  as  Mr.  Cripps  thinks,  epithelioma  is  a  dis- 
ease of  the  follicles  of  the  rectum,  may  not  villous  tumors  be 
epithelioma  of  the  villi  ?  not  so  malignant  from  the  fact  that 
it  grows  outward  from  the  mucous  membrane  instead  of 
sinking  into  it,  and  thus  preventing  the  ready  escape  of  the 
cells.  Three  of  my  cases  I  will  relate  in  some  detail,  as  they 
are  my  most  recent  ones  : — 

Dr.  D — ,  a  physician,  came  to  me  in  September  of  1875. 
He  is  sixty  years  of  age,  a  small  and  spare  man,  with  an 
aspect  of  countenance  suggesting  malignant  disease.  He  is 
married  and  has  a  family.  He  says  that  for  quite  two  years 
and  a  half  he  has  suffered  from  piles,  something  occasionally 
protruding  from  the  anus  on  going  to  stool.  About  two 
years  since  he  began  to  loose  blood,  and  a  considerable 
quantity  of  glairy  mucous  was  discharged  from  the  bowel. 
The  tumor,  for  it  was  single,  grew  rapidly,  and  always  came 
down  at  the  closet,  and  occasionally  on  exertion.  It  bled 
profusely,  often  half  a  pint  at  one  action  of  the  bowel,  and 
he  had  fainted  in  the  closet  from  loss  of  blood.     On  being 


VILLOUS    TUMOR    OF    THE    RECTUM.  24I 

returned  inside  the  sphincters  the  bleeding  ceased.  Latterly 
/.  e.y  within  the  last  few  months,  he  had  much  difficulty  in 
returning  it,  owing  to  its  large  size,  as  it  gradually  became  as 
large  as  a  man's  fist.  It  had,  he  said,  a  soft,  spongy  feel, 
and  the  blood  could  be  squeezed  out  of  it  by  the  hand. 
Three  weeks  back  he  found  the  tumor  began  to  disintegrate 
on  his  handling  it,  and  now  it  had  so  decreased  that  he 
could  readily  return  it  into  the  bowel.  His  health  had  been 
very  materially  failing;  he  was  weak,  often  giddy,  with  noises 
in  his  head  and  dimness  of  vision. 

I  gave  him  an  enema,  and  on  going  to  the  closet  he 
brought  outside  the  anus  a  very  vascular  tumor,  looking  like 
a  sponge,  about  the  size  of  a  large  hen's  egg,  and  bleeding 
profusely,  as  it  was  tightly  girt  about  by  the  sphincter.  On 
examining  the  bowel  I  found  the  tumor  was  connected  with 
the  mucous  membrane  by  a  short,  thick,  tough  peduncle, 
which  was  quite  smooth.  When  the  growth  was  with  some 
difficulty  returned  into  the  bowel,  you  could  scarcely  realize 
the  fact  that  so  large  a  tumor  existed;  only  the  pedicle  could 
be  felt,  as  something  hard;  it  was  attached  about  an  inch  and 
a  half  up  the  rectum,  on  the  left  side  and  rather  toward  the 
dorsum.  The  peduncle  was  about  the  size  of  the  forefinger 
in  thickness.  On  September  226.,  assisted  by  Mr.  Baly, 
then  the  resident  surgeon  at  St.  Mark's  hospital,  the  tumor 
being  got  well  down,  I  passed  a  thick,  double  ligature,  by 
means  of  a  rectangular  needle,  through  the  pedicle,  close  to 
its  attachment  to  the  rectum,  and  tied  it  tightly,  in  halves. 
I  felt  a  large  vessel  pulsating  forcibly  in  the  pedicle,  and,  of 
course,  avoided  wounding  this  with  the  needle.  The 
peduncle  was  so  short  that  I  did  not  dare  to  cut  off  the 
tumor,  fearing  if  it  did  so  the  ligatures  might  slip.  The 
growth  was  lobulated  and  distinctly  villous. 

The  patient  made  an  excellent  recovery,  and  speedily 
gained  health  and  strength.  In  about  twelve  months  after 
this  operation  Dr.  D —  again  came  to  me  and  said  the  growth 
had  returned.  On  examination  I  found  he  was  right,  but 
the  tumor  was  small.  This  time  there  was  absolutely  no 
peduncle,  and  it  was  broad  at  the  base  and  felt  hard  at  its 
attachment  to  the  rectum.  This  case  led  me  to  doubt  the 
innocent  character  of  villous  tumor.  I  agreed  to  remove  the 
growth  again,  and  the  patient  being  placed  under  ether,  I 
was  able  to  dilate  the  sphincters,  and  partly  by  knife  and 
partly  by  ligature,  to  extirpate  the  whole  very  thoroughly. 
After  this  the  patient  recovered,  and  there  had  been  no 
16 


242  VILLOUS   TUMOR    OF    THE   RECTUM. 

return  up  to  a  very  recent  date,  when  I  saw  this  gentleman. 
Seen  again  in  November,  1881.  Epithelioma  has  developed 
around  the  rectum,  extending  from  the  site  of  the  old 
growth. 

A  young  man,  pale  and  thin,  was  sent  to  me  at  St  Mark's 
Hospital  in  April  of  1877,  by  Dr.  Way,  of  Southsea.  He 
said  he  had  piles,  that  they  came  down  at  the  closet  and  on 
walking  about;  they  did  not  bleed  much,  but  he  lost  quan- 
tities of  watery  discharge,  which  frequently  ran  away  and 
saturated  his  trousers.  On  administering  an  enema  he  strained 
down  a  large  tumor,  the  size  of  a  hen's  egg,  with  a  peduncle 
broad  and  thin;  it  was  ligatured  in  four  portions  and  cut  off. 
He  made  a  good  recovery,  and  left  the  hospital  in  three 
weeks,  quite  well.  On  examining  the  bowel  after  the  liga- 
tures came  away  no  trace  of  hardness  or  peduncle  could  be 
felt;  the  tumor  was  situated  at  the  dorsal  surface  of  the 
bowel  and  to  the  right  side. 

J.  B — ,  set,  52,  was  admitted  into  St.  Mark's  Hospital, 
under  my  care,  on  the  2 2d  of  April,  1878.  He  was  in 
appearance,  the  color  of  old  wax,  was  very  feeble,  and  looked 
prematurely  aged.  His  heart's  action  was  intermittent,  and 
a  soft  blowing  sound  could  be  heard.  He  said  he  had 
suffered  from  what  he  considered  to  be  the  piles  for  some 
years,  but  lately  he  had  a  very  large  mass  come  outside.  He 
lost  quantities  of  blood,  and  there  was  also  a  discharge 
from  the  bowel  "like  gum  water."  He  had  a  tendency  to 
diarrhoea;  great  difficulty  was  experienced  in  returning  the 
growth,  which  bled  all  the  while  it  was  protruded.  On 
examining  the  tumor,  when  down,  it  was  found  to  be  quite 
as  large  as  a  man's  fist,  spongy,  lobulated,  with  the  villi 
greatly  hypertrophied;  the  growth  was  so  vascular  that  you 
could  scarcely  touch  it  without  arterial  blood  spurting  out. 
On  passing  the  finger  into  the  rectum  the  tumor  was  found 
to  grow  all  round  the  bowel  and  there  was  absolutely  no 
stem;  all  attempts,  therefore,  to  deal  with  it  by  ligature,  in 
the  ordinary  way,  could  not  be  successful.  As  an  operation 
was  necessary,  to  save  the  man's  life,  I  -determined  to  remove 
the  tumor,  and  I  thought  I  could  succeed  by  ligature  and 
strong  harelip  pins.  With  much  trouble  and  great  loss  of 
blood  I  managed  to  strangulate  the  whole  mass.  When  I 
perforated  the  stump  of  the  growth  with  a  needle  threaded 
with  a  double  ligature  and  tied  each  way,  the  bleeding  was 
tremendous  at  the  point  where  the  segments  were  drawn 
apart,  therefore  I  could  find  no    way   to   strangulate   and 


VILLOUS   TUMOR    OF   THE    RECTUM.  243 

arrest  haemorrhage  save  by  the  harelip  needles  and  the 
figure-of-eight  ligature.  The  actual  cautery  and  perchloride 
of  iron  had  no  power  over  the  bleeding  of  this  huge  cauli- 
flower-looking growth.  Of  course  it  had  to  be  left  protrud- 
ing from  the  anus.  No  return  until  December,  1880,  when 
the  rectum  was  attacked  by  epithelioma,  and  the  growth 
extended  high  up.     He  died.  May,  1881. 

The  patient  was  exceedingly  exhausted,  not  being  in  a 
condition  to  support  such  a  sudden  loss  of  a  quantity  of 
blood.  For  a  few  days  I  was  in  some  anxiety  about  the  ter- 
mination of  the  case,  but  he  rallied  wonderfully,  and  at  the 
end  of  a  few  days  I  thought  him  safe  if  no  secondary 
haemorrhage  took  place;  this  fortunately  did  not  occur. 
The  decomposing  mass  was  kept  quite  sweet  by  charcoal 
powder,  and  he  got  on  well;  the  part  separated  without  any 
bleeding  whatever  and  left  a  large  granulating  sore;  just  as 
we  thought  all  was  right  he  was  attacked  with  diarrhoea,  very 
difficult  to  control,  in  fact,  nothing  was  of  service  but  a 
powder  consisting  of  bismuth,  soda,  charcoal,  and  opium, 
which  eventually  cured  him.  He  was  not  sufficiently  recov- 
ered to  leave  the  hospital  until  two  months  after  the  opera- 
tion. I  have  seen  this  patient  frequently  since  he  was  dis- 
charged, and  no  return  of  the  tumor  had  taken  place,  but 
high  up  in  the  rectum  I  find  some  small  nodules;*  whether 
they  would  develop  into  anything  serious  I  could  not  for 
some  time  judge,  but  I  watched  him  with  interest  and  some 
anxiety.  After  the  operation  his  general  health  became 
quite  restored  and  his  appearance  wonderfully  improved. 

I  have  mentioned  my  belief  that  villous  tumors  at  times 
shed  themselves,  and  I  will  relate  the  case  which  supports 
my  view: 

Miss  H ,  a  maiden  lady,  of  fifty  or  more  years  of  age, 

was  kindly  sent  to  me  by  Dr.  Morten,  of  Kilburn.  She  was 
a  tall,  spare  woman,  with  a  rather  worn  expression  of  face. 
Her  history  was  that  about  twenty  years  ago  she  had  suffered 
from  losses  of  blood  from  the  rectum,  and  also  from  a  dis- 
charge which  she  described  as  like  thin  starch.  This  fluid 
flowed  away  at  times  in  abundance.  At  this  time  her  health 
was  much  broken,  she  had  pains  in  her  back  and  inability  to 
take  exercise;  nothing  came  down  on  the  bowels  acting. 
Her  bowels  were  very  constipated  and  she  took  some  strong 

*  Since  this  was  written  epithelioma  developed,  and  the  patient  died 
in  May,  1881. 


244  VILLOUS    TUMOR    OF    THE    RECTUM. 

aperient  pills,  the  result  being  that  when  the  bowels  acted 
"  a  large  mass  of  flesh  came  away,  and  the  bleeding  was  so 
severe  that  she  fainted."  After  this  she  had  no  more  bleed- 
ing or  watery  discharge,  and  quickly  recovered  her  health. 
After  being  well  until  about  twelve  or  fifteen  months  ago,  to 
her  horror,  the  bleeding  and  discharge  recommenced.  She 
consulted  medical  men,  who  said  her  case  was  one  of  piles, 
and  various  treatment  was  adopted  without  any  effect.  She 
told  me  that  portions  of  a  fleshy,  soft  character  came  away 
sometimes  at  stool.  She  had  straining,  pains,  and  general 
debility.  She  was  ordered  to  take  charcoal,  bismuth,  and 
soda  powders  three  times  in  the  day,  and  use  an  injection  of 
rhatany.  I  requested  her  to  send  me  a  specimen  of  what 
she  passed  when  straining.  My  examination  detected  noth- 
ing but  a  relaxed,  voluminous  mucous  membrane,  which 
came  down  into  the  rectum,  but  neither  by  finger  nor  specu- 
lum could  I  detect  any  disease.  In  a  few  days  after  the 
consultation  the  patient  sent  me  some  of  the  discharge,  and 
I  found  remarkably  good  specimens  of  villous  growth,  some 
pieces  being  as  large  as  a  hazel  nut.  I  saw  this  lady  once 
more,  and  used  all  means  to  see  or  feel  the  growth,  but  could 
not  get  at  it.  I  was  quite  sure  of  my  diagnosis,  and  could 
only  tell  her  I  hoped  in  time  the  stem  of  the  growth  would 
increase  in  length  and  come  down  within  reach,  so  that  one 
could  remove  the  disease.  A  few  months  after  this  I  had  a 
letter  informing  me  that  the  charcoal  had  caused  a  stoppage 
in  the  bowels,  for  which  large  doses  of  aperients,  castor  oil 
among  them,  had  been  used,  to  obtain  relief,  and  that  when 
action  was  at  length  obtained,  a  mass  came  away,  not  so 
large  as,  but  much  resembling,  the  one  she  had  passed  years 
years  ago,  and  that  she  felt  much  relieved.  She  sent  me  a 
portion  of  the  specimen,  and  that,  sure  enough,  was  a  villous 
growth.  Whether  there  will  be  any  further  return  remains 
to  be  seen. 

The  case  is  a  very  interesting  one,  and  leads  me  to  think 
that  villous  growths  may  break  away  from  the  bowel  more 
often  than  is  supposed,  and  I  remember  some  very  puzzling 
cases  I  have  seen  which  were  possibly  similar  to  the  one  I 
have  related. 


MISCELLANEOUS.  245 

CHAPTER  XXI. 

MISCELLANEOUS. 

In  this,  my  concluding  chapter,  I  intend  to  treat  briefly  of 
several  forms  of  disease  of  the  rectum,  which  are  of  some- 
what rare  occurrence. 

NEURALGIA    OF    THE   RECTUM. 

I  can  see  no  reason  why  neuralgia  should  not  sometimes 
attack  the  rectum  as  well  as  any  other  part  of  the  body  ;  no 
doubt  many  other  affections  have  been  erroneously  called 
neuralgic,  and  I  am  ready  to  confess  that  I  have  more  than 
once  considered  pains  as  neuralgic  which  I  later  on  dis- 
covered to  originate  from  a  lesion  of  structure. 

Very  slight  erosions  or  even  inflammation  of  a  spot  in  the 
rectum  may  set  up  much  pain  ;  and  at  the  same  time  be  so 
difficult  to  discover  as  to  baffle  the  closest  and  most  search- 
ing investigation. 

I  have  been  in  the  habit  of  calling  pain  in  the  rectum  or 
sphincter  muscles  neuralgic,  when  I  have  not  been  able  to 
find  out  the  slightest  lesion,  sign  of  inflammation,  or  dis- 
charge of  any  kind,  and  where  the  pain  was  not  aggravated 
by  action  of  the  bowels  ;  this  I  always  consider  an  import- 
ant point  in  diagnosis. 

In  my  cases  the  pain  has  been  at  times  severe,  at  others 
absent,  and  only  in  two  instances  was  it  constant.  The 
patients  have  been  mostly  delicate,  irritable,  or  nervous  peo- 
ple, who  have  been  subject  to  neuralgic  pains  in  other  parts. 
I  have  noticed  the  attack  follow  direct  exposure  to  wet  and 
cold  by  sitting  upon  damp  grass.  One  attack  predisposes  to 
another  ;  several  times  in  private  practice  I  have  been  con- 
sulted by  the  same  patient. 

Usually  you  will  find  in  these  cases  general  debility,  but 
in  addition  disorders  of  the  digestive  organs  ;  very  often  the 
liver  is  much  affected  ;  it  will  therefore  not  do  to  commence 
your  treatment  with  tonics  and  anti-neuralgic  remedies  ; 
first  of  all  unload  and  put  the  abdominal  viscera  into  condi- 
tion, and  then  quinine,  iron,  strychnia,  and  hypodermic 
injections  of  morphia  may  at  once  cure  your  patient. 
Attention  to  this  point  is  all  important  ;  in  some  instances, 
however,  one  has  to  confess  to  an  inability  to  do  more  than 
temporary  good  ;  nothing  appears  to  cure  the  malady. 


246  MISCELLANEOUS. 

When  the  pain  seems  quite  confined  to  the  sphincter  mus- 
cle there  was  always  spasmodic  contraction,  and  I  believe 
forcible  dilatation  of  the  anus,  performed  as  I  have  before 
described,  to  be  the  best  treatment ;  after  this  is  done  a 
hypodermic  injection  of  morphia  will  often  cure  this  affec- 
tion, which  I  used  to  consider  a  very  intractable  form  of 
myalgia. 

There  are  other  nervous  diseases  of  the  rectum  described 
by  authors,  but  they  are  very  rare  indeed  ;  one  of  them, 
which  is  called  "  irritable  rectum,"  I  think  is  really  the 
result  of  a  chronic  inflammation  of  the  mucous  membrane, 
as  in  such  cases  I  have  observed  much  heat  in  the  bowel 
and  tenesmus,  as  well  as  a  discharge  of  mucus.  These  cases 
are  best  treated  by  very  gentle  laxatives,  to  keep  the  bowels 
acting,  by  alkalies  with  bitter  infusions,  and  by  insufflation 
of  bismuth  and  charcoal  into  the  rectum.  This  treatment 
will  soon  allay  the  irritability,  and  after  this  is  accomplished 
the  cure  will  be  rendered  permanent  by  injections  of  rha- 
tany  and  starch,  with  small  doses  of  the  liquid  extract  of 
opium. 

REMOVAL    OF    COCCYX. 

I  have  seen  many  female  patients  suffering  from  what  has 
been  considered  neuralgic  pain  in  the  rectum,  but  really  the 
pain  was  most  distinctly  referable  to  the  sacro-coccygeal 
joint.  These  are  most  intractable  cases,  and  on  four  occa- 
sions I  have  removed  the  coccyx,  in  the  hope  of  curing  the 
disease  which  was  wearing  out  the  mind  and  body  of  the 
patients. 

]My  first  case  was  a  married  woman,  aet.  54,  with  seven 
children.  She  had  for  years  been  complaining  of  pain  in 
the  rectum  and  at  the  end  of  the  spine,  which  rendered  her 
quite  incapable  of  performing  her  household  duties.  She 
could  not  sit  down  except  on  a  ring-shaped  air-cussion,  and 
when  from  home  she  always  wore  under  her  dress  a  couple 
of  pads  to  catch  the  buttocks,  so  that  the  end  of  the  spine 
should  not  touch  anything. 

If  the  bowels  were  confined  she  had  great  pain  before  and 
at  the  time  of  their  acting  rather  than  afterwards.  If  she 
stooped,  and  suddenly  raised  herself,  the  pain  "  was  like  a 
knife  going  through  the  very  bottom  of  the  back."  She 
could  walk  but  a  short  distance,  and  going  up  stairs,  was  a 
very  painful  exertion  to  her. 

On  examining  the  rectum  no  fissure  or  ulcer  was  discover- 


MISCELLANEOUS.  247 

able,  but  when  the  finger  was  pressed  on  the  coccyx,  so  as 
to  move  it — and  it  moved  exceedingly  freely  and  easily — 
she  complained  most  bitterly. 

As  nothing  I  could  do  seemed  to  benefit  her.  and  she  had 
been  under  many  eminent  physicians  and  surgeons  without 
getting  better,  I  determined  to  remove  the  coccygeal  bone 
at  the  joint ;  and  this  I  did.  Making  a  vertical  incision 
along  the  bone,  and  taking  care  not  to  wound  the  rectum,  I 
dissected  it  out  and  disarticulated  it  without  any  difficulty. 
There  did  not  appear  to  be  any  appreciable  pathological 
change  in  the  bone.  The  wound  healed  rapidly,  and  I  was 
much  pleased  to  find  that  the  patient  was  cured.  She  was 
able,  nine  months  after  the  operation,  to  sit  down  in  com- 
fort, and  to  walk  about  without  any  pain. 

Encouraged  by  this  success  I  operated,  some  years  back, 
in  a  very  similar  case,  at  St.  Mark's  Hospital.  The  patient 
was  an  unmarried  woman,  32  years  of  age,  who  had  been 
for  years  suffering  from  pains  in  the  rectum  and  end  of  the 
spine.  Her  symptoms  were  almost  precisely  like  those  I 
have  described,  and  there  was  no  lesion  in  the  bowel,  but 
she  had  an  intussusception,  not  to  any  great  extent,  of  the 
rectum.  This  made  me  less  sanguine  of  success,  but  as  the 
pain  was  undoubtedly  sacro-coccygeal  I  removed  the  bone 
and  the  wound  healed  well.  Although  she  is  not  perfectly 
free  from  pain  she  can  sit  down  in  comfort,  which  she  could 
not  do  at  all  before,  and  in  many  other  respects  she  is 
improved. 

Two  years  ago  I  removed  the  coccygeal  bone  from  a  gen- 
tleman who  had  sustained  a  most  painful  injury  by  falling 
on  the  side  of  a  rowing  boat  from  which  he  was  getting  out. 
He  had  suffered  much  afterwards,  and  a  fistula  formed  in 
the  bowel.  This  had  been  opened,  but  he  was  no  better, 
when  he  began  to  get  about  the  pain  returning  in  all  its  pre- 
vious acuteness.  On  carefully  examining  him  I  found  that 
a  sinus  ran  close  to  the  coccyx,  and  bare  bone  could  be 
detected  with  the  probe,  so  no  doubt  a  periosteal  abscess 
had  formed.  Believing  the  bone  to  be  diseased,  I  requested 
him  to  allow  me  to  remove  it,  and  he  consented.  When  the 
bone  was  excised  there  was  not  any  necrosis  evident,  but  it 
was  unusually  dense,  so  I  concluded  inflammation  had  been 
present.  I  was  rather  in  doubt  about  the  case  doing  well, 
but  a  perfect  recovery  was  the  result,  all  pain  being  gone 
before  the  wound  had  healed. 

I  by  no  means  intend  to  advocate  the  frequent  removal 


248  MISCELLANEOUS. 

of  the  coccyx  for  pains  in  the  neighborhood  of  that  bone, 
yet  I  think  in  some  cases,  where  all  other  means  have  been 
exhausted,  and  there  is  good  evidence  that  the  pain  is 
induced  by  every  movement  of  the  bone,  its  excision  is 
called  for,  and  may  be  the  means  of  curing  an  otherwise 
incurable  disease.  I  do  not  see  any  particular  danger  in  the 
operation,  and  that  the  coccyx  may  be  dispensed  with  with- 
out any  evil  resulting  is,  I  think,  certain. 

INFLAMMATION. 

Inflammation  of  the  rectum  may  occur  in  both  a  chronic 
and  acute  form.  The  chronic  variety  obtains  in  old  people. 
The  symptoms  are  a  sensation  of  heat  and  fullness  in  the 
rectum,  frequent  desire  to  go  to  stool,  and  great  tenesmus  ; 
there  may  be  a  discharge  of  blood  and  mucus.  With  these 
symptoms  you  would  suspect  impaction,  but  a  digital  exam- 
ination will  settle  that  point.  Injections  of  starch  and 
opium  are  very  beneficial,  but  I  think  in  the  aged  the  most 
efficient  medicines  are  turpentine,  aloes,  confection  of  black 
pepper  and  copaiba.  I  usually  order  frequent  and  small 
doses  of  Barbadoes  aloes  ;  it  acts  as  a  stimulant  to  the  rec- 
tum, induces  a  healthy  action,  and  very  soon  the  disorder 
subsides.  Hamamelis  is  another  useful  remedy  ;  it'  is,  in 
fact,  rapidly  curative  in  some  cases.  It  may  be  used  as  an 
injection  and  also  administered  by  the  mouth. 

Acute  inflammation  of  the  rectum  resembles  dysentery  in 
its  symptoms,  but  it  is  distinguished  from  it  by  the  absence 
of  abdominal  pain  or  tenderness  and  severe  constitutional 
disturbance  ;  the  pain  is  generally  confined  to  the  sacrum 
and  perineum  ;  the  bladder  is  often  sympathetically  affected, 
and  there  is  not  infrequently  difficulty  in  passing  water. 

The  most  effective  treatment  would  be  leeches  around  the 
anus,  hot  baths,  injections  of  water  in  small  quantities,  as 
hot  as  can  be  borne  ;  to  this  may  be  added  a  drachm  of 
Battley's  sedative.  A  hot  bath  followed  by  a  hypodermic 
injection  of  morphia  is  likely  to  benefit.  The  patient  should 
keep  the  recumbent  position,  take  very  light,  unstimulating 
nourishment,  and  no  irritating  purges  should  be  given.  If 
it  be  necessary  to  relieve  the  bowel  of  its  contents  a  flask  of 
warm  olive  oil  as  an  enema  is  the  best  that  can  be  employed. 
I  have  seen  very  few  such  cases  in  this  country,  but  they 
are  not  so  uncommon  in  hot  climates 


IN  DEX. 


ABSCESS,  a  cause  of  fistula,  i6. 
formation  of,  after  oper- 

tion  on  fistula,  44. 

Acid,  nitric,  applied  to  internal 
haemorrhoids,  89. 

applied  to   procidentia  recti, 

124. 

Acorns,  powdered,  for  diarrhoea  of 
procidentia,  130. 

Actual  cautery,  used  by  nati\e  doc- 
tors for  cure  of  piles,  9, 

Anal  fistula,  21. 

Anus,  eczema  of,  138. 

itching  of,  137. 

Arterial  haemorrhoids,  72. 

Artificial  anus  (see  colotomy). 

Ascarides,  a  new  cause  of  prurituc 
ani,  143. 

BLADDER,  diseases  of,  compli- 
cating haemorrhoids,  84. 
Bleeding  from  rectum  after  opera- 
tions on  fistula,  40. 

on  piles,  114. 

Blind  external  fistula,  20. 

internal  fisuula,  20. 

Bone  stud  for  cure  of  fistula,  27. 

CANCER  of  rectum,  202. 
colotomy  in,  227. 

complicating      haemorrhoids, 

112. 

duration  of  life  in,  202. 

ordinary  site  of,  204. 

question  of  heredity  in,  203. 

treatment  of,  206. 

varieties  of,  203. 

Capillary  haemorrhoids,  71. 

treatment  of,  76. 

Carbolic   acid,    injection   of,    into 

haemorrhoids,  89. 
Caustic  paste   applied  to  internal 

haemorrhoids,  87. 


Cauterization,  linear,    for  internal 
haemorrhoids,  92. 

ponctuee,  for  internal  haemor- 
rhoids, 91  • 

Cautery,     galvanic,      for     internal 
haemorrhoids,  95. 

Paquelin,  for  internal  haemor- 


cause   of    rectal 


rhoids,  95. 
Chancroid   as    a 

ulceration,  191. 
Chian  turpentine,  useless  in  cancer 

of  the  rectum,  207. 
Children,  polypus  recti  in,  131. 

prolapsus  recti  in,  124. 

Clamp  and  scissors  for  removal  of 

haemorrhoids,  96. 
Coccyx,  removal  of,  246. 
Coexistence  of  fistula  with  phthisis, 

47. 
Colloid  cancer  of  the  rectum,  202. 
Colotomy  in  cancer  of  the  rectum, 

226. 
Complete  fistula,  20. 
Concretions  in  the  rectum,  164. 
Contraction  of  bowel   after  opera- 
tions for  haemorrhoids,  107. 
Cough,    as   influencing   success  of 

operation   for  fistula  in  ano  in 

phthisical  patients,  56. 
Crushing  instruments,  author's,  for 

treating    internal   haemorrhoids, 

99. 

DIAGNOSIS  of  rectal  diseases, 
9,  II. 

Digital  exploration  of  rectum,  14. 

Dilatation  of  sphincters,  14. 

for  cure  for  fissure,  163. 

for  cure  of  haemorrhoids,  97. 

Drainage  tubes,  use  of,  after  oper- 
ation for  fistula,  19. 

Drinkers,  preparatory  treatment 
for  operating  on,  12. 


249 


250 


INDEX. 


Dysenter}'  a    cause  of  stricture  of 
the  rectum,  190. 

ECRASEUR,   the,    for  removal 
of  hsemorrhoids,  S6. 
Eczema,  a  cause  of  pruritus  ani, 

138. 
Elastic  ligature  for  cure  of  fistula, 

2S. 
Encephaloid  cancer  of  rectum,  202, 

case  of,  208. 

Epithelioma  of  rectum,,  202. 
Eversion  of  rectum,  how  to  effect, 

15.  .       . 
Examination  of  patients,  how    to 

conduct,  II. 
suffering  from  fistula  or  sinus, 

21. 
Excision  of  internal  haemorrhoids, 

85. 
Exploration  of  rectum,  12. 
Exploration  of  haemorrhoids,  60. 
External  fistula,  forms  of,  20. 
Extirpation  of  portions  of  rectum, 

for  cancer,  209. 
cases  of,  212. 

FECAL  impaction,  159. 
Fissure  of  the  rectum,  143. 

cause  of  pain  in,  154. 

diagnosis,  145. 

method  of  operating  for,  152. 

nervous  symptoms  connected 

with,  153. 

symptoms  of,  143. 

treatment  of,  147. 

by    dilating    the 


158. 


148. 


by    dividing   the 


uterine      disease 


sphincters, 

sphincters, 

coexisting 


with,  146. 
Fistula  in    ano,    blind,     external, 

20. 

blind,  internal.  20. 

cases  of  cure  without  cuttings 


34- 


of  spontaneous  cure  of,  24. 
causes  of,  16. 
complete,  20. 
complicating      haemorrhoids, 


no. 


dangerous  kinds  of,  22. 
difficult  cases  of,  44. 


Fistula,   haemorrhage   after  opera- 
tions on,  41. 

horse-shoe  form  of,  22. 

in  conjunction  with   phthisis, 

47- 
internal   aperture  of,  how  to 

find,  25. 

operations  on,  34. 

prevalence    of,    statistics   of. 


10,  16. 

—  treatment  of,  by  cutting,  34. 

—  by  the  elastic  ligature,  28. 
treatment   of,    subsequent  to 


operation,  43. 
Fistulse   and  sinuses  in   phthiscal 

patients,  peculiarities  of  58. 
Forcible  dilatation  of  sphincters  for 

cure  of  fissure,  158. 

for  cure  of  haemorrhoids,  97. 

dilatation  of  stricture  of  the 

rectum,  cautions  regarding,  14. 

GALVANIC  cautery  for  internal 
haemorrhoids,  95. 
Glycerine     in     the     treatment  of 

haemorrhoids,  84. 
Gouty     patients,    precautions     in 

operating  on,  12. 
pruritus  and  occurring  in,  141. 

HEMORRHAGE  after  applica- 
tion of  nitric  acid,  126. 

in  operations  on  fistula,  41. 

in  operations  on  hemorrhoids, 

114. 

in  operations  on  hemorrhoids, 

treatment,  119. 

Haemorrhoids,  classification  of,  60. 

complications  of,  39,  IIO. 

external,  causes  of,  61. 

diagnosis  and  symptoms   of, 

62. 

treatment  of.  63 . 

internal,  cases  of,  66. 

causes  of,  76. 

views  of  French  authors  con- 
cerning, 66. 

constitutional  treatment  for, 


80. 


—  cure  of,    without    operation, 
80, 

—  dangers  from  losses  of  blood 
from,   76. 

—  in  pregnant  women,  73. 


INDEX. 


251 


Haemorrhoids,  operations  on,  85 

structure  of,  71. 

symptoms  of,  70. 

varieties  of,  70. 

prolapsed,   122, 

protruded,  how  to  replace,  77. 

Hernia  of  bowel  complicating  pro- 

cidenta  recti.  127. 
Horse-shoe  fistula,  22. 
Hospital,  St.    Mark's,   analysis  of 

4,000  cases  at,  10. 

IMPACTION  of  f£eces,  159. 
1     cases  of,   160. 


causes  of,  159. 


Impaction  complicating  haemor- 
rhoids, 109, 

treatment  of,  163. 

Incontinence  of  faeces  after  opera- 
tion for  fistula,  42. 

occurring  in  procidentia,  127. 

India  rubber  ligature,  author's 
probe  and  canula  for  passing,  31. 

for  fistula  in  ano,  28. 

Professor  Dittel's  method  of 

introducing,  32. 

Inflammation  of  rectum,  248. 

a  cause  of  stricture,  198. 

Injection,  use  of,  when  examining 
patients,  13. 

Instrument  for  applying  ointments 
to  the  rectum,  195. 

Introduction  of  hand  and  arm  into 
intestine,  14. 

Intussusception  of  the  rectum, 
123. 

Irritable    ulcer    of     the     rectum, 

143- 
Itching  of  the  anus,  136. 

LIGATURE,  elastic,  treatment 
of  fistula  by  the,  28. 

treatment  of  internal  haemor- 
rhoids by  the,  102. 

statistics  of,  108. 

Liver,  examination  of,  in  cases  of 
rectal  disease,  12, 

Luke,  Mr.,  tourniquet  for  fistula  in 
ano,  38. 

Lupoid  ulcer  of  the  rectum.  232. 


M 


ORTALITY,    smallness     of, 
after  ligature  of  haemorrhoids, 
108. 


NEURALGIA  of    the   rectum, 
245. 
Nitric    acid    applied    to     internal 
haemorrhoids,  76,  87. 

applied  to  procidentia  recti  in 

children,  124. 

OBSTRUCTION  of  rectum 
from  cancer,  205. 

from  impacted  faeces,  189. 

Ointments,  instrument  for  apply- 
ing to  rectum,  195. 

Operations  on  cancer  of  the  rectum, 
207. 

on  fistula  in  ano,  34. 

after  treatment  of,  43. 

on  internal  hemorrhoids,  85. 

on    phthisical    patients,     for 

fistula,  48. 

Opium  for  relief  of  cancer  of  rec- 
tum, 2q6. 

PAIN,  question  of,  after  ligature 
of  haemorrhoids,  106. 

Painful  ulcer  of  rectum  (see  Fis- 
sure). 

Paquelin  cautery  for  cure  of  proci- 
dentia, 127, 

Parturition,  injuries  during,  a 
cause  of  ulceration  of  the  rec- 
tum, 188. 

Pathology  of  internal  haemorrhoids, 
Verneuil's  views  regarding,  66, 
67. 

Pelvic  fistula,  15. 

Phthisis  as  a  complication  of  fistula, 

47. 
Piles  (see  Hsemorrhoids). 
Pollock,  Mr.  George,  on  treatment 

of  haemorrhoids  by  crushing,  99. 
Polypus  recti,  130. 

cases  of,  133. 

complicating  fissure,  146. 

complicating      haemorrhoids, 


113- 


treatment,  136. 
varieties,  131. 


Procidentia  recti,  122. 

causes  of,  124. 

in  children,  124. 

treatment,   125. 

by  actual  cautery,  127. 

by      removing     portions    of 

mucous  membrane,  126. 


252 


INDEX. 


Prolapsus  ani  (see  Procidentia). 

Pruritus  ani,  136. 

accompanied  by  haemorrhoids, 

143. 

causes,  137. 

due  to  ascarides,  143. 

treatment,   138. 

varieties,  138. 

RECTAL  abscess,  leading  to  fis- 
tula, 17. 

treatment  of,  17. 

diseases,  causes  of,  g. 

prevalence  in  foreign  coun- 
tries, 9. 

statistics  of,  St.  Mark's  Hos- 
pital, 10. 

Rectum,  cancer  of,  202. 

concretions  in,  164. 

examination  of,  11. 

extirpation  of,  209,  210 

fissure  of,  143. 

inflammation  of,  248 

neuralgia  of,  245. 

polypus  of,  130, 

prolapsus  of,  122. 

rodent  ulcer  of,  232. 

ulceration  and  stricture  of,  166 

•  villous  tumor  of,  239. 

Recumbent  position  after  opera- 
tions on  haemorrhoids,  105. 

Removal  of  coccyx,  246. 

Retention  of  urine  after  operation 
on  internal  haemorrhoids,  107. 

'-  "  due  to  impaction  of  faeces,  162. 

SALMON, MR.,  method  of  oper- 
ating for  fistula,  36. 
Sarcotome,  Dr.  Hollis's,  30. 
Scirrhus  of  rectum,  202. 
Scissors  and  director,  author's,   for 
operating  on  fistula  in  ano,  37, 

34- 

Scrofula,  a  cause  of  ulceration  of 
rectum,  128. 

Sinuses,  necessity  for  dividing  all, 
in  operating  for  fistula,  188. 

Soft  polypus  of  the  rectum,  131. 

Spasm  of  sphincters  after  opera- 
tions, how  to  prevent,  104. 

Speculum  ani,  kinds  and  use  of,  13. 

Sphincters,  dilatation  of,  14. 

— —  for  cure  of  fissure,  157. 

for  haemorrhoids,  97. 


Statistics   of  coexistence  of  fistula 

with  phthisis,  47. 

with  rectal  diseases,  10, 

Strangulation  of  protrusion  in  cases 

of  procidentia,  144. 
Stricture  of  the  rectum,  166. 

without  ulceration,  198. 

Syphilis,  a  cause  of  fissure  of  the 

rectum,  144. 
of   stricture    of    the  rectum, 

190. 

TETANUS     after    ligature    of 
haemorrhoids,  107. 
Tuberculosis  a  cause  of  ulceration 

of  the  rectum,  188. 
Tumor,  villous,  of  the  rectum,  239. 

ULCER,  painful  (see  Fissure). 
rodent,  of  the   rectum, 

232. 

Ulceration  and  stricture  of  the  rec- 
tum, 245. 

linear,  rectotomy  for,  176. 

and  stricture  of  the  rectum, 

opinions   as   to   venereal  causa- 
tions, 191. 

statistics  of  seventy  cases  of. 


171. 


symptoms  of,  166 

treatment  of,  193. 

twenty-nine  cases   of,  in  pri- 
vate practice,  177. 

Urine,  necessity  for  examining  be- 
fore operation,  12. 

retention  of,  after  operations 

on  haemorrhoids,  107. 

retention  of,  due  to  impaction 


of  faeces,  162. 

Uterine  diseases  complicating  fis- 
sure, 146. 

haemorrhoids,  81. 

Uterus,  state  of,  as  affecting  rectal 
diseases,  12. 

VENOUS  haemorrhoids,  descrip- 
tion of,  72. 
Vemeuil,    Prof.,    views    of,    as    to 
causation     of     internal  haemor- 
rhoids, 67. 
Villous  tumor  of  rectum,  239. 

TTTHITE  piles.  Si> 


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1882 


Allinrhara 


Fistula,   haemorrhoids,    painful 

'^ll^^'^^;^''^''^^^^.    prolapsus,    and 
other  disease  of  the  rectum. 


%t  %(^f 


"TTSSrSEJ' 


